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College  of  S^f^v^imm  anb  burgeons; 
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HUGHES'  PRACTICE  OF  MEDICINE 


SCOTT 


TENTH  EDITION 


THE   LEATHER  BOUND  SERIES 

OF 

MEDICAL  MANUALS 


BINNIE.  Operative  Surgery.  By  John  Fairbaim  Binnie,  A.  M.,  C.  M. 
(Aberdeen);  Professor  of  Surgery,  Kansas  State  University;  Member 
American    Surgical    Association. 

Volume  I.  Fourth  Edition.  Operations  on  the  Head,  Neck,  Nerves,  Trunk, 
Genito-Urinary  System,  xi+832  pages.  Illustrated  by  713  Engravings, 
some  of  which  are  printed  in  colors.  Flexible  Leather,  Gilt  Edges, 
Round  Comers.  $3.50 

Volume  n.  Vascular  System,  Bones  and  Joints,  Amputations.  viii+5S3 
pages.  550  Illustrations.  Flexible  Leather,  Gilt  Edges,  Round 
Corners.  $3.50 

GREENE.  Medical  Diagnosis.  Third  Edition.  By  Charles  Lyman  Greene, 
M.  D.,  of  St.  Paul,  Professor  of  the  Theory  and  Practice  of  Medicine  in 
the  University  of  Minnesota.  With  7  Colored  Plates  and  248  other  Illus- 
trations. 1 2 mo.  725  pages.  Flexible  Leather,  Gilt  Edges,  Round 
Comers.  $3.50 

HUGHES.    Compend  of  the  Practice  of  Medicine.   Tenth  Edition.    Revised 

and  Enlarged  by  R.  J.  E.  Scott,  M.  A.,  B.  C.  L.,  M.  D.,  Attending  Physi- 
cian to  the  Demilt  Dispensary;  Formerly  Attending  Physician  to  the 
Bellevue  Dispensary,  New  York.  With  63  Illustrations,  xvii-l-878 
pages.    Flexible  Leather,  Gilt  Edges,  Round  Corners.  $2.50 

KYLEo  Manual  of  Diseases  of  the  Ear,  Nose  and  Throat.  Third  Edition. 
By  John  Johnson  Kyle,  B.S.,  M,  D.,  Clinical  Professor  of  Otology, 
Rhinology  and  Laryngology  in  the  Medical  College  of  Indiana;  Otologist, 
Rhinologist  and  Laryngologist  to  the  City  Hospital,  .Indianapolis; 
Member  of  the  American  Laryngological,  Rhinological  and  Otological 
Society;  President  of  the  American  Academy  of  Ophthalmology  and 
Oto-Laryngology.  With  178  Illustrations.  xxxi+ 627  pages.  Flexible 
Leather,  Gilt  Edges,  Round  Comers.  $3.00 

SLUSS.  Emergency  Surgery.  Second  Edition.  By  John  W.  Sluss,  A.  M., 
M.  D.,  Professor  of  Anatomy,  Indiana  University  School  of  Medicine; 
formerly  Professor  of  Anatomy  and  Clinical  Surgery,  Medical  College 
of  Indiana;  Surgeon  to  the  Indianapolis  City  Hospital.  With  605  Illus- 
trations. xiv+748  pages.  i2mo.  Flexible  Leather,  Gilt  Edges,  Round 
Comers.  $3.50 

STEWART.  Manual  of  Surgery.  By  Francis  T.  Stewart,  M.  D.,  Professor  of 
Surgery,  Philadelphia  Polyclinic;  Associate  in  Surgery,  Jefferson  Medical 
College,  Philadelphia,  etc.  504  Illustrations.  ix-f778  pages.  Flexible 
Leather,  Gilt  Edges,  Round  Comers.  $3.50 

THORNDIKE.  Manual  of  Orthopedic  Surgery.  By  Augustus  Thorndike, 
M.  D.,  Assistant  Surgeon  to  the  Children's  Hospital,  Boston;  Member 
American  Orthopedic  Association.  191  Illustrations.  i2mo.  Flexible 
Leather,  Gilt  Edges,  Round  Comers.  $2.50 

***  Other  Volumes  in  Preparation. 


P.     BLAKISTON'S     SON    &    CO. 

Publishers  :  :         PHILADELPHIA 


HUGHES' 

PRACTICE   OF  MEDICINE 

INCLUDING  A  SECTION  ON  MENTAL  DISEASES 
AND  ONE  ON  DISEASES  OF  THE  SKIN 


TENTH  EDITION  REVISED  AND  ENLARGED 


BY 

R.  J.  E.  SCOTT,  M.  A.,  B.  C.  L.,  M.  D. 

ATTENDING   PHYSICIAN    TO    THE    DEMILT    DISPENSARY;    FORMERLY    ATTENDING 

PHYSICIAN   TO   THE   BELLEVUE    DISPENSARY,    NEW   YORK 

AUTHOR   OF   "  THE   STATE    BOARD   EXAMINATION   SERIES,"    ETC.,    ETC. 


WITH  63  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S  SON  &  CO. 

1012  WALNUT  STREET 
1911 


nil 


Copyright,  1911,  by  P.  Blakiston's  Son  &  Co. 


Printed   by 

The  Maple  Press 

York,  Pa. 


PREFACE  TO  THE  TENTH  EDITION. 


The  time  that  has  elapsed  since  the  appearance  of  the  last 
edition  has  necessitated  very  many  changes  and  additions. 
The  Table  of  Contents  will  show  that  the  general  arrangement 
has  been  considerably  modified.  For  example,  Pneumonia  and 
Tuberculosis  no  longer  appear  as  Diseases  of  the  Lungs,  but 
take  their  rightful  place  among  the  Infectious  Diseases;  and 
Herpes  Zoster  will  be  found  among  the  Diseases  of  the  Nerves, 
rather  than  among  the  Skin  lesions.  Several  new  sections  have 
been  added,  such  as  Pellagra,  Glandular  Fever,  Foul  Breath, 
Cammidge's  Reaction,  Paralysis  of  the  Laryngeal  Muscles. 
The  book  as  a  whole  has  been  thoroughly  revised,  much  of  it 
has  been  rewritten,  sections  that  were  obsolete  or  unnecessary 
have  been  omitted,  and  almost  every  page  shows  changes.  The 
new  edition  contains  one  hundred  pages  of  reading  matter  more 
.than  the  previous  one,  besides  a  much  fuller  index.  Some  of 
the  older  prescriptions  have  been  discarded,  and  many  new  ones 
have  been  introduced.  The  sections  on  treatment  will  be  found 
much  more  complete,  and  the  prescriptions  more  numerous, 
than  in  any  other  similar  work.  It  has  been  assumed  that 
Diagnosis  and  Treatment  are  the  main  business  of  the  prac- 
titioner, and  that  those  who  use  this  book  are  anxious  to  find 
out  what  is  the  matter  with  their  patients,  and  then  to  alleviate 
or  cure,  as  the  case  may  be.  To  this  end  numerous  tables  of 
differential  diagnosis  have  been  added,  and  other  useful  sum- 
maries have  been  incorporated  into  the  text.  The  number  of 
charts  and  illustrations  has  been  increased  from  27  to  63;  and 
every  effort  has  been  made  to  render  the  volume  as  useful  as 
possible  to  both  students  and  practitioners.  A  few  paragraphs 
have  already  appeared  in  the  Medical  Record,  under  the  heading 
of  State  Board  Questions  and  Answers;  and  acknowledgment  is 
hereby  made  to  the  Editor  and  Publishers  of  that  paper  for 
permission  to  reproduce  the  same. 

R.  J.  E.   Scott. 
New  York. 

V 


CONTENTS. 


Introduction i 

INFECTIOUS  DISEASES. 

Fevers 5 

Table  of  Exanthemata lo 

Simple  Continued  Fever 1 1 

Influenza 12 

Typhoid  Fever 16 

Paratyphoid  Fever       31 

Typhus  Fever  . 32 

Cerebrospinal  Fever 34 

Relapsing    Fever 38 

Malta  Fever 40 

Malaria 41 

Intermittent  Fever 45 

Remittent  Fever 48 

Pernicious  Malarial  Fever 49 

Malarial  Cachexia 52 

Blackwater  Fever 52 

Yellow  Fever 53 

Dengue 58 

Scarlet  Fever 59 

Measles 66 

Rubella .  69 

Small-pox 69 

Vaccination       75 

Varicella 77 

Erysipelas 78 

Mumps 80 

Diphtheria 82 

Glanders  and  Farcy 93 

Foot  and  Mouth  Disease 94 

vii 


Vlll  CONTENTS. 

Cholera 95 

Dysentery 103 

Trypanosomiasis no 

Bubonic  Plague iii 

Tetanus 112 

Hydrophobia 114 

Anthrax 116 

Whooping  Cough 118 

Rheumatic  Fever 121 

Lobar  Pneumonia 127 

Tuberculosis 141 

Pulmonary  Tuberculosis 141 

Acute  Miliary  Tuberculosis 142 

Pneumonic  Phthisis 144 

Tubercular  Phthisis 148 

Fibroid  Phthisis 152 

Treatment  of  Pulmonary  Tuberculosis 153 

Leprosy 160 

Glandular  Fever 162 


CONSTITUTIONAL  DISEASES. 

Chronic  Articular  Rheumatism 163 

Muscular  Rheumatism ' 164 

Arthritis  Deformans ■ 167 

Gout       169 

Lithemia 173 

Rickets 175 

Hemophilia 177 

Scorbutus .  178 

Purpura 180 

Diabetes  Mellitus 182 

Diabetes  Insipidus 187 


THE  INTOXICATIONS  AND  SUNSTROKE. 

Alcoholism 188 

Pellagra 197 

Heat  Stroke 198 


CONTENTS.  IX 

DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

DISEASES   OF  THE   MOUTH. 

Introduction 200 

Catarrhal  Stomatitis       201 

Aphthous  Stomatitis 202 

Ulcerative  Stomatitis 203 

Thrush 204 

Gangrenous  Stomatitis       205 

Mercurial  Stomatitis                    206 

Ludwig's  Angina 206 

DISEASES   OF   THE   TONGUE. 

Coating  of  the  Tongue 207 

Glossitis 207 

Syphilis  of  the  Tongue 208 

Ulceration  of  the  Tongue 208 

Leukoplakia  Buccalis 209 

Foul  Breath 209 

DISEASES   OF  THE   PHARYNX  AND   TONSILS. 

Acute  Catarrhal  Pharyngitis 210 

Chronic  Pharyngitis , 211 

Ulceration  of  the  Pharynx 212 

Acute  Tonsillitis 213 

Hypertrophy  of  the  Tonsils 215 

DISEASES   OF  THE   ESOPHAGUS. 

Esophagitis 216 

Esophageal  Obstruction 216 

Cancer  of  the  Esophagus 217 

DISEASES   OF  THE   STOMACH. 

Diagnostic  Technic 218 

External  Examination 218 

Internal  Examination.    (Examination  of  Stomach  Contents.)  219 

Acute  Gastritis 224 

Irritant  and  Corrosive  Poisons       227 

Chronic  Gastritis 229 

Peptic  Ulcer;  Gastric  and  Duodenal 234 


X  CONTENTS. 

Cancer  of  the  Stomach 238 

Gastric  Dilatation 242 

Gastroptosis 243 

Hematemesis 245 

Gastralgia 24'6 

Dyspepsia 249 

DISEASES   OF  THE  INTESTINES. 

Intestinal  Indigestion 253 

Intestinal  Colic .    . 256 

Constipation 257 

Diarrhea 259 

Catarrhal  Enteritis       263 

Croupous  Enteritis      266 

Cholera  Morbus 268 

Enterocolitis 270 

Cholera  Infantum 274 

x\ppendicitis ..277 

Proctitis 281 

Intestinal  Obstruction ' 282 

INTESTINAL  PARASITES. 

Tapeworms — -Cestodes .287 

Round  Worms — Nematodes      291 

Dracontiasis  (Guinea  Worm  Disease) 298 

DISEASES   OF  THE   LIVER. 

Preliminary  Considerations 298 

Congestion  of  the  Liver 300 

Abscess  of  the  Liver 302 

Acute  Yellow  Atrophy 304 

Cirrhosis  of  the  Liver. 305 

Amyloid  Liver 309 

Hydatid  Cyst  of  the  Liver 311 

Syphilis  of  the  Liver 312 

Carcinoma  of  the  Liver       •     ■  313 

Sarcoma  of  the  Liver 314 

DISEASES   OF  THE   BILE   PASSAGES  AND   GALL  BLADDER. 

Jaundice 315 

Cholelithiasis 3^7 

Acute  Infectious  Cholecystitis 321 


CONTENTS.  XI 

DISEASES   OF   THE   PANCREAS. 

Acute  Pancreatitis 322 

Chronic  Pancreatitis 323 

Cancer  of  the  Pancreas 324 

Cysts  of  the  Pancreas 324 

Pancreatic  CalcuH 325 

The  Cammidge  Reaction 325 

DISEASES   OF   THE   PERITONEUM. 

Peritonitis 326 

Ascites 331 

DISEASES  OF  THE  URINARY  ORGANS. 

The  Urine 334 

DISEASES   OF   THE    KIDNEYS   AND   BLADDER. 

Congestion  of  the  Kidneys 350 

Acute  Parenchymatous  Nephritis 352 

Chronic  Parenchymatous  Nephritis 355 

Chronic  Intestinal  Nephritis 359 

Amyloid  Kidney      364 

Pyelitis       366 

Nephrolithiasis 368 

Hydronephrosis 371 

Tuberculosis  of  the  Kidney 372 

Perinephritic  Abscess,  or  Paranephritis 372 

Acute  Uremia 373 

Movable  Kidney      377 

Cystitis _ 379 

DISEASES  OF  THE   BLOOD  AND   DUCTLESS  GLANDS. 

Examination  of  the  Blood 382 

Abnormal  States  of  the  Blood       388 

Anemia. 390 

Chlorosis 392 

Progressive  Pernicious  Anemia 396 

Leukocythemia 398 

Hodgkin's  Disease 401 

Status  Lymphaticus 402 

Splenic  Anemia 402 


Xll  CONTENTS. 

1 

Addison's  Disease • 403     ' 

Exophthalmic  Goitre      404     i 

Myxedema 406     \ 

I 

DISEASES  OF  THE  CIRCULATORY  SYSTEM.  ] 

] 

Physical  Diagnosis 408     j 

Symptomatology ...416      ! 

DISEASES   OF   THE   PERICARDIUM.  j 

Acute  Pericarditis 419     j 

Chronic  Pericarditis 424      i 

Hydropericardium 425      j 

i 

DISEASES   OF  THE   ENDOCARDIUM,  i 

Acute  Endocarditis 426  ; 

Malignant  Endocarditis 429  i 

Chronic  Endocarditis      .430  ; 

Mitral  Regurgitation 431  ; 

Aortic  Regurgitation 433  ; 

Tricuspid  Regurgitation 438  ^ 

Pulmonary  Regurgitation       438  ' 

Mitral  Obstruction 439  I 

Aortic  Obstruction       440 

-  Tricuspid  Obstruction 442  ] 

Pulmonary  Obstruction 442  ; 

Relative  Frequency  of  Valvular  Defects 442  ! 

Combined  Valvular  Lesions 443  j 

Diagnosis  and  Treatment  of  Valvular  Diseases 443  i 

DISEASES  OF  THE  MYOCARDIUM.   • 

Hypertrophy  of  the  Heart " 446      ; 

Dilatation  of  the  Heart : 449      ; 

Acute  Myocarditis 453 

Chronic  Myocarditis 454      ; 

Fatty  Heart 457 

FUNCTIONAL  AFFECTIONS   OF   THE   HEART.  ^ 

Palpitation  of  the  Heart 459      j 

Tachycardia 461      i 

Bradycardia 462      i 

Arrhythmia 463      | 

Angina  Pectoris ;  464 


CONTENTS.  Xlll 


DISEASES   OF  THE  ARTERIES. 


Arteriosclerosis 467 

Aneurysm  of  the  Aorta       469 

Aneurysm  of  the  Arch  of  the  Aorta 470 

Aneurysm  of  the  Thoracic  Aorta 473 

Aneurysm  of  the  Abdominal  Aorta 473 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Physical  Diagnosis 475 

Association  of  the  Physical  Signs 499 

General  Symptomatology 500 

DISEASES   OF  THE   NASAL  PASSAGES. 

Acute  Nasal  Catarrh 505 

Chronic  Nasal  Catarrh 508 

DISEASES   OF  THE   LARYNX. 

Acute  Catarrhal  Laryngitis •  5 1 1 

Edematous  Laryngitis 514 

Spasmodic  Laryngitis 516 

Laryngismus  Stridulus 518 

Chronic  Laryngitis       , 520 

Syphilitic  Laryngitis ,...521 

Tuberculous  Laryngitis       .; 522 

DISEASES   OF  THE   BRONCHIAL  TUBES. 

Acute  Bronchitis 524 

Chronic  Bronchitis       529 

Fibrinous  Bronchitis 535 

Hay  Fever 537 

Asthma 540 

DISEASES   OF  THE   LUNGS. 

Emphysema 545 

Hemoptysis      549 

Congestion  of  the  Lungs 552 

Edema  of  the  Lungs 553 

Bronchopneumonia 555 

Fibroid  Pneumonia 559 


XIV  CONTENTS.  ' 

DISEASES   OP  THE   PLEURA. 

Pleurisy ^ 560   ; 

Hydrothorax ♦. ■    .     .    566   j 

Pneumothorax 566   j 

DISEASES  OF  THE   NERVOUS  SYSTEM.  ! 

i 

General  Symptomatology 568   ^ 

DISEASES   OF   THE   CEREBRAL  MEMBRANES.  f 

Pachymeningitis       579' 

Acute  Leptomeningitis 581    | 

Tubercular  Meningitis "*■ 585! 

DISEASES   OF   THE   CEREBRUM.  1 

Congestion  of  the  Brain     ..■ 59ii 

Cerebral  Anemia 593    i 

Cerebral  Hemorrhage. 595| 

Cerebral  Thrombosis  and  Embolism 602    ; 

Cerebral  Abscess 607    '■ 

Cerebral  Tumor 609    i 

Aphasia 613    ! 

Vertigo .6151 

Migraine 619: 

Acute  Hydrocephalus 622    1 

Congenital  Hydrocephalus 623; 

DISEASES  OF  THE  SPINAL  CORD.   *  ; 

Spinal  Hyperemia 625  j 

Spinal  Pachymeningitis       627  J 

Spinal  Meningitis 629  1 

Acute  Meylitis 631  j 

Localization  of  the  Functions  of  the  Segments  of  the  Spinal  Cord  633  j 

Infantile  Spinal  Paralysis 636  | 

Chronic  Progressive  Bulbar  Paralysis       639  I 

Progressive  Muscular  Atrophy 641  j 

Pseudo- Hypertrophic  Muscular  Paralysis 644  j 

Acute  Ascending  Paralysis 645  i 

Spinal  Sclerosis 645  < 

Primary  Lateral  Sclerosis 646  j 

Locomotor  Ataxia 648  i 

Ataxia  Paraplegia 652  I 


CONTENTS.  XV 

Cerebrospinal  Sclerosis 653 

Hereditary  Ataxia 656 

Differential  Diagnosis  of  Chronic  Diseases  of  the  Spinal  Cord.     .  657 

Syringomyelia       658 

Caisson  Disease 659 

DISEASES   OF   THE   NERVES. 

Simple  Neuritis 660 

Multiple  Neuritis 662 

Beri-beri 665 

Herpes  Zoster 666 

Neuralgia 667 

Neuralgia  of  the  Fifth  Nerve 668 

Cervico-occipital  Neuralgia 668 

Cervico-brachial  Neuralgia 669 

Dorso-intercostal  Neuralgia        669 

Lumbo-abdominal  Neuralgia 669 

Sciatica 669 

Erythromelalgia 670 

Prognosis  and  Treatment  of  Neuralgia  in  General 670 

Facial  Paralysis 673 

Paralysis  of  the  Laryngeal  Muscles 674 

GENERAL  NERVOUS  DISEASES. 

Chorea 675 

Epilepsy 678 

Hysteria 683 

Neurasthenia 687 

Raynaud's  Disease      688 

Tetany 689 

Occupation  Neuroses       690 

Paralysis  Agitans 691 

Acromegaly       693 

MENTAL  DISEASES. 

General  Considerations 693 

Classification  of  Insanity 694 

Melancholia       696 

Mania 699 

Epileptic  Insanity 705 

Circular  Insanity 707 


XVI  CONTENTS. 

Katatonia 708 

Delusional  Insanity 709 

Paranoia 712 

General  Paralysis .714 

Dementia 718 

DISEASES  OF  THE  SKIN. 

General  Symptomatology ...722 

Anemia  of  the  Skin 724 

Hyperemia  of  the  Skin 724 

INFLAMMATIONS   OP  THE   SKIN. 

Erythema  Multiforme 725 

Erythema  Scarlatinoides 726 

Erythema  Nodosum 727 

Erythema  Induratum 728 

Utricaria 728 

Angioneurotic  Edema     .     .     . 732 

Eczema 733 

Treatment  of  Special  Forms  and  Varieties  of  Eczema 745 

Eczema  Seborrhoicum •    •  755 

Impetigo  Contagiosa  ....: 755 

Ecthyma 756 

Dermatitis  Herpetiformis 757 

Pemphigus 758 

Pompholyx 760 

Herpes  Simplex .761 

Lichen  Planus       762 

Prurigo 764 

Acne       ........'....:    764 

Acne  Rosacea 769 

Sycosis  Vulgaris  ..v 772 

Psoriasis 773 

Pityriasis  Rosea 777 

Dermatitis ..778 

Furunculus 780 

Carbunculus 782 

PARASITIC  DISEASES. 

Tinea  Circinata 785 

Tinea  Tonsurans 788 


CONTENTS.  XVll 

Tinea  Sycosis  _ 791 

Tinea  Versicolor      793 

Tinea  Favosa 794 

Scabies       797 

Pediculosis 801 

HYPERTROPHIES   OF   THE   SKIN. 

Lentigo 803 

Chloasma       804 

Callositas 807 

Clavus 808 

Ichthyosis -. 809 

Verruca 812 

Molluscum  Epitheliale 814 

Comedo 814 

Milium 816 

Sebaceous  Cyst 817 

Keratosis  Pilaris       817 

Hypertrichosis 818 

Elephantiasis ...818 

Onychauxis 819 

ATROPHIES   OF  THE   SKIN. 

Albinism 819 

Vitiligo 819 

Scleroderma. 820 

Morphea 820 

Canities 821 

Atrophy  of  the  Nails 821 

Alopecia 821 

Alopecia  Areata 822 

NEW   GROWTHS   OF  THE   SKIN. 

Keloid 823 

Xanthoma 823 

Lupus  Erythematosus 824 

Lupus  Vulgaris 826 

vScrofuloderma 829 

Syphiloderma 829 

DISORDER  OF  SECRETION. 

Hyperidrosis -335 


XVIU  CONTENTS. 

Anidrosis 838 

Sudamina 838 

Miliaria 839 

Seborrhea 841 

DISORDER    OF    SENSATION. 

Pruritus 845 

Index 849 


THE 
PRACTICE  OF  MEDICINE. 


INTRODUCTION. 


The  practice  of  medicine  is  the  exercise  of  medical  art,  and 
embraces  all  that  pertains  to  the  knowledge,  prevention,  and 
cure  of  those  departures  from  normal  to  which  the  term  dis- 
ease is  applied. 

Disease  may  be  organic  when  there  is  structural  change, 
or  functional  when  there  are  no  demonstrable  lesions.  It  is 
questionable    whether    these    forms    can    exist    independently. 

Pathology  is  the  study  of  disease.  It  explains  the  origin 
and  development  {pathogenesis),  causes  {etiology),  nature 
{morbid  anatomy),  and  clinical  history  {morbid  physiology) 
of  the  various  abnormal  conditions  that  may  disturb  the 
economy.  Pathology  is  said  to  be:  (i)  general  when  it  is 
concerned  with  the  study  of  morbid  conditions  common  to  many 
diseases,  (2)  special  when  it  is  restricted  to  the  study  of  individ- 
ual diseases. 

Pathogenesis  is  that  subdivision  of  pathology  which  treats 
of  the  origin  and  development  of  morbid  processes  or  disease. 

Lesions  are  appreciable  anatomical  changes. 

Etiology  is  that  branch  of  general  pathology  which  considers 
the  causes  of  disease.  These  may  be  internal,  external,  ordi- 
nary, specific,  primary,  secondary,  predisposing,  and  exciting. 
The  internal  or  intrinsic  causes,  include  those  having  their 
origin  in  the  mind  such  as  prolonged  mental  application, 
intense  or  long-continued  emotional  excitement,  long-con- 
tinued   mental    depression,    etc.,    and    in    the  accumulation  of 


2  INTRODUCTION. 

certain  products  in  the  blood  as  the  result  of  faulty  secretion 
or  excretion,  or  the  absorption  of  ptomains  from  the  digestive 
tract. 

The  external  or  extrinsic  causes,  embrace  traumatism  and 
substances  introduced  into  the  body  from  without  such  as 
poisons,  bacteria,  toxins,  etc. 

The  ordinary  causes  are  those  to  which  we  are  constantly 
exposed   such   as   atmospheric   and  climatic   changes. 

The  specific  or  special  causes  are  in  nearly  every  instance 
microorganisms  (bacteria  or  protozoa) ;  many  varieties  of  which 
are  capable  of  producing  distinct  diseases,  for  example,  the 
tubercle  bacillus  producing  tuberculosis,  the  Comma  bacillus 
causing  Asiatic  cholera,  and  the  Plasmodium,  malarice  (a 
protozoon)  giving  rise  to  malaria.  A  disease  produced  (or 
supposed  to  be  produced)  by  a  specific  cause  or  microorganism 
is  said  to  be  infectious;  if  the  disease  is  communicable  by 
contact  it  is  spoken  of  as  contagious.  Infectious  diseases 
may  or  may  not  be  contagious  but  all  contagious  diseases 
are  infectious.  The  distinction  between  infectious  and  con- 
tagious diseases  is  not  of  much  importance  now. 

A  primary  cause  is  the  cause  in  which  the  affection  took 
its   origin.     Traumatism   is   a   common   primary   cause. 

A  secondary  cause  is  a  contributory  cause  and  the  term  is 
usually  applied  to  the  various  morbid  excretory  products 
of  the  blood. 

The  predisposing  causes  embrace  any  inherited  or  acquired 
susceptibility  to  disease. 

An  inherited  predisposition  is  also  a  diathesis,  as  examples 
of  which  may  be  mentioned  the  rheumatic  and  tubercular 
diatheses. 

Acquired  predisposition  depends  upon  the  race,  sex,  age, 
occupation,    habits,    and   environment   of   the    individual. 

The  exciting  causes  are  those  that  immediately  precede  and 
precipitate  an  attack  of  any  disease.  The  influence  of  atmos- 
pheric changes  in  the  production  of  rheumatism  may  be 
mentioned  as  an  example. 

When  a  disease  is  found  in  a  certain  locality  more  or  less 


INTRODUCTION.  3 

constantly,  it  is  said  to  be  endemic;  when  it  affects  a  very 
large  part  of  a  community,  it  is  said  to  be  epidemic;  when  it  is 
present  in  very  large  areas  at  a  time,  as  over  several  countries, 
it  is  said  to  be  pandemic;  and  when  it  is  found  only  in  single 
or  stray  cases  in  a  given  locality,  it  is  said  to  be  sporadic. 

Morbid  anatomy  or  pathologic  anatomy  is  that  divison  of 
pathology  which  considers  the  structural  change  or  lesions 
of  disease.  It  may  therefore  be  gross  or  microscopic  {histo- 
pathology).  Microscopic  morbid  anatomy  may  be  said  to 
include  the  study  of  the  tissues  {histology),  the  blood  {hemat- 
ology),   and  the  various  bacteria  {bacteriology) . 

The  clinical  history  of  a  disease  includes  all  the  data  ref- 
erable to  the  manifestations  of  the  disease  process,  or  its  mor- 
bid physiology.  It  embraces  the  symptomatology ,  physical 
signs,  complications,  sequels,  diagnosis,  prognosis,  treatment, 
and  termination. 

Symptomatology  is  the  study  of  the  various  symptoms  and 
signs  whereby  the  disease  is  detected.  They  may  be  object- 
ive, when  evident  to  the  senses  of  the  observer,  such  as  red- 
ness, swelling,  high  temperature,  etc.,  or  subjective  when  the 
patient  alone  is  aware  of  their  existence,  such  as  pain,  numb- 
ness, vertigo,  and  nausea.  The  earliest  recognizable  symptoms 
are  called  the  prodromes. 

The  period  of  incubation  is  the  interval  that  exists  between 
the  entrance  of  a  poison  into  the  system  and  the  manifestation 
of  its  symptoms. 

Pathognomonic  symptoms  are  those  especially  indicative 
of  certain  diseases  as,  for  instance,  the  rusty  sputum  of  pneu- 
monia   and  the  eruption  of  small-pox. 

An  acute  disease  is  one  in  which  the  invasion  is  sudden  and 
rapid,  and  as  a  rule  severe;  when  the  symptoms  develop 
less  rapidly  and  are  less  intense,  the  disease  is  said  to  be  sub- 
acute; when  gradual  or  slow  in  development,  of  longer  dura- 
tion, and  of  lessened  intensity,  the  disease  is  said  to  be  chronic. 

The  physical  signs  are  objective  symptoms  and  are  elicited 
by  inspection,  mensuration,  palpation,  percussion,  and  aus- 
cultation. 


4  INTRODUCTION. 

Complications  are  morbid  conditions  that  may  arise  in  the 
course  of  the  original  disease. 

The  sequels  of  a  disease  are  the  morbid  phenomena  which 
remain  as  the  result  of  disease. 

Diagnosis  of  disease,  or  the  discrimination  of  diseases,  im- 
plies a  complete,  exact,  and  comprehensive  knowledge  of  the 
phenomena  under  consideration,  as  regards  their  origin,  seat, 
extent,  and  nature. 

A  direct  diagnosis  is  made  when  the  morbid  condition  is 
revealed  by  a  combination  of  clinical  phenomena,  or  some 
one  or  more  pathognomonic  symptoms. 

A  differential  diagnosis  is  the  result  when  the  diseases  re- 
sembling each  other  are  called  to  mind  and  eliminated  from 
each  other. 

A  diagnosis  by  exclusion  is  made  by  proving  the  absence  of 
all  diseases  which  might  give  rise  to  the  symptoms  observed, 
except  one,  the  presence  of  which  is  not  actually  indicated 
by  any  positive  symptoms. 

The  prognosis  of  a  disease  is  the  conclusion  or  prediction 
relating  to  the^  future  course  or  termination  of  the  affection 
under  consideration,  or  the  art  of  making  such  predictions. 
Like  diagnosis,  it  depends  largly  on  clinical  experience. 

Treatment  of  disease  may  be  prophylactic  or  preventive; 
and  curative.  It  may  be  divided  into  hygienic,  dietetic,  and 
medicinal  treatment.  It  is  abortive  when  the  disease  is  checked 
in  its  early  stage,  expectant  when  the  affection  is  allowed 
to  pursue  its  natural  course,  palliative  when  the  object  is  only 
to  relieve  suffering,  and  restorative  when  it  aims  to  overcome 
weakness  and  prostration. 

The  termination  of  a  disease  may  be  in  cure,  secondary  pro- 
cesses, or  death.  Cure  may  be  affected  by  a  slow  return  to 
health    {lysis)    or    abruptly    with    a    critical  discharge  {crisis). 

Secondary  processes  are  those  in  which  the  original  affec- 
tion is  substituted  by  a  new  morbid  process,  as  in  the  case  of 
endocarditis  following  rheumatism. 

Death  may  be  brought  about  by  a  progressively  increasing 
debilty  {asthenia),  as  in  phthisis,  cancer,  and  Bright's  disease; 


FEVERS.  5 

by  an  insufficient  quantity  or  quality  of  the  blood  {anemia) ; 
by  non-aeration  of  the  blood  {apnea)  as  in  lung  affections 
and  croup;  or  by  cerebral  involvement  {coma)  as  is  seen  in 
uremia,  narcotic  poisoning,  and  apoplexy. 

Terminology. — Words  ending  in  itis  indicate  inflammatory 
conditions,  such  as  peritonitis ;  those  ending  in  rhoea  or  rhea 
refer  to  the  transudation  of  liquid  from  a  mucous  surface,  as, 
for  example,  diarrhea;  those  ending  in  algia  denote  painful 
conditions  independent  of  inflammation  as  gastralgia;  those 
ending  in  csmia  or  emia  signify  a  morbid  condition  of  the 
blood,  as,  for  instance,  anemia;  those  ending  in  uria  relate  to 
abnormal  conditions  of  the  urine  as  albuminuria;  while  those 
terminating  in  oma  signify  a  tumor,  for  example  sarcoma  and 
carcinoma.  A  morbid  condition  of  a  part  without  any  indica- 
tion of  its  nature  is  designated  by  the  suffix  pathy,  as  encephal- 
opathy and  adenopathy. 

The  prefix  hydro  indicates  a  dropsical  condition,  as,  for 
instance,  hydroperitoneum;  the  prefix  pneumo  denotes  the  ab- 
normal presence  of  air  in  a  part,  as  pneumothorax ;  the  prefix 
peri  refers  to  the  investing  membrane  of  a  part,  thus  peri- 
nephritis indicates  inflammation  of  the  membrane  surround- 
ing the  kidney.  The  connective  tissue  surrounding  a  part  is 
designated  by  the  prefix  para  as,  for  example,  parametritis, 
the  term  for  inflammation  of  the  connective  tissue  surround- 
ing the  uterus. 


INFECTIOUS  DISEASES. 
FEVERS. 

Fever  is  a  condition  in  which  the  body  temperature  is  above 
normal  (98.6°F.)  and  which  is  attended  by  quickened  circula- 
tion and  respiration,  marked  tissue  changes  causing  propor- 
tionate wasting  of  the  body,  and  disordered  secretions  giving 
rise  to  anorexia,  thirst,  constipation,  and  scanty,  high-colored 
urine  of  increased  specific  gravity.     It  may  be  due  to  a  dis- 


6  I-EVERS. 

order  of  the  sympathetic  nervous  system  inducing  disturb- 
ances of  the  vaso-motor  filaments,  or  to  a  derangement  of 
the  nerve-centers  adjacent  to  the  corpus  striatum  which 
govern  heat  production,  distribution,  and  dissemination. 
Fever  may  be  said  to  result  from  a  disturbance  of  the  balance 
which  normally  exists  between  heat  production  and  heat  dis- 
sipation, and  is  usually  toxemic  in  origin. 

Rise  of  temperature  is  the  most  prominent  feature  of  all  fevers 
and  can  be  accurately  determined  only  by  the  use  of  the  clinical 
thermometer  placed  in  the  mouth,  axilla,  rectum,  or  vagina. 
The  mouth  is  usually  selected  by  preference.  There  is  a  slight 
variation  in  the  temperature  of  these  various  sites,  as  is  shown 
in  the  following  table: 

Axilla,  or  groin 98  .4°  F.  (36 .  9°  C.) 

Mouth 98.6°  F.  (37°       C.) 

Rectum,  or  vagina 99 .  5°  F.  (3  7  .  5°  C.) 

Subnormal  Temperature. — A  fall  of  temperature  below  normal 
is  a  less  frequent  occurrence  but  may  be  observed  in  collapse, 
cholera,  convalescence  from  acute  febrile  diseases,  and  in  chronic 
affections  such  as  valvular  heart  disease,  myxedema,  diabetes, 
certain  nervous  diseases,  cancer,  etc. 

Degrees  of  Pyrexia :  ^ 

Feverishness 99°  to  100°  F. 

Slight  fever 100°  to  101°  F. 

Moderate  fever 101°  to  103°  F. 

High  fever 104°  to  105°  F. 

Intense  fever.  . 105°  to  106°  F. 

Hyperpyrexia 106°  F.  or  over. 

Fever  may  be  divided  into  three  stages :  invasion,  in  which  the 
temperature  gradually  rises ;  fastigium  or  stadium,  in  which  its 
acme  is  reached  and  to  some  extent  maintained;  and  deferves- 
cence or  decline,  in  which  the  temperature  gradually  drops  until  it 
becomes  normal. 


FEVERS.  7 

The  decline  of  a  fever  may  be:  dj  by  lysis,  in  which  the  tem- 
perature falls  gradually,  as  in  typhoid,  acute  rheumatism, 
pleurisy,  and  bronchopneumonia;  or  (2)  by  crisis,  in  which  it 
drops  suddenly  and  is  attended  by  sweating  and  increased  flow 
of  urine,  as  in  erysipelas,  malaria,  measles,  pneumonia,  relapsing 
fever,  and  typhus  fever. 

Diurnal  variations  (usually  1°  F.)  are  common  to  all  fevers. 
In  most  cases  the  highest  point  is '  reached  in  the  early  part 
of  the  evening  (6  p.  m.)  and  the  lowest  at  a  corresponding 
hour  in  the  morning  (6  a.  m.),  but  occasionally  this  order  is 
reversed. 

Types. — Fever  may  be  considered  as  of  three  types,  continued, 
remittent,  and  intermittent.  In  continued  fever  the  diurnal  varia- 
tion is  seldom  more  than  one  or  one  and  a  half  degrees.  This 
type  is  seen  in  scarlet  fever,  pneumonia,  and  typhus  fever. 

In  remittent  fever,  the  diurnal  variation  is  greater  but  the 
minimum  temperature  never  reaches  the  normal  point.  This 
variety  is  observed  in  septic  conditions,  remittent  fever,  and 
typhoid  fever. 

In  intermittent  fever,  the  diurnal  variation  is  very  marked  and 
the  temperature  drops  to  normal  or  below.  As  examples  of  this 
type  may  be  mentioned  the  septic  fevers,  intermittent  malaria, 
relapsing  fever,  and  the  fever  associated  with  impacted  gall- 
stones. 

Some  fevers  are  characterized  by  but  one  intermission  or  re- 
mission. For  instance,  variola  has  a  remission  on  the  third  day, 
measles  has  a  fall  of  temperature  on  the  third  or  fourth  day  with 
a  subsequent  rise,  dengue  has  an  intermission  on  the  third  or 
fourth  day  which  may  extend  over  forty-eight  or  seventy-two 
hours,  and  yellow  fever  has  an  intermission  on  the  third  or  fourth 
day. 

The  pulse  usually  bears  a  direct  relation  to  the  temperature 
and  in  most  cases  a  rise  of  1°  F.  is  attended  by  an  increase  of 
8  to  10  beats  of  the  pulse  per  minute.  Thus: 


FEVERS. 


A  temperature  of: 

Corresponds  to 

a  pulse  of: 

98°  F.  or  36.7°  C 

60 

99°  F.  or  37.2°  C 

70 

100°  F.  or  37.8°  C 

80 

101°  F.  or  38.4°  C 

90 

102°  F.  or  38.9°  C 

100 

io3°F.  or  39.5°C 

no 

104°  F.  or  40     °  C 

120 

105°  F.  or  40.5°  C 

130 

106°  F.  or  41.1°  C 

140 

Note. — This  relation  does  not  hold  good  in  Yellow  fever  after  the 
first  few  days;  in  this  disease  the  temperature  remains  high,  while 
the  pulse  declines  to  50  or  even  40  per  minute. 


General  Treatment  of  all  Fevers. — All  patients  with  fever 
should  be  placed  at  rest  in  bed  in  a  moderately  heated,  quiet, 
and  well- ventilated  room;  and,  if  possible,  a  sensible  and  well- 
trained  nurse  should  be  employed.  The  patient  should  be 
nourished  by  the  administration  of  milk,  beef-tea,  animal 
broths,  and  peptonized  or  other  highly  nutritious  food  in 
small  quantities  at  frequent  but  regular  intervals.  Solids 
should  be  interdicted.  The  secretions  should  be  rendered 
free  by  the  administration  of  laxatives,  diuretics,  and  dia- 
phoretics.    Plenty  of  pure  cold  water  should  be  given. 

The  temperature  may  be  reduced  by  hydrotherapy  or  drugs. 
Hydrotherapy  includes  the  cold  pack,  the  cold  bath,  and 
sponging.  The  drugs  employed  to  reduce  temperature  are 
quinin,  antipyrin,  antifebrin,  and  phenacetin,  but  their  de- 
pressing action  renders  them  somewhat  dangerous,  with  the 
exception  of  the  first  named;  and  the  tendency  is  now  more 
and  more  toward  hydrotherapy  and  less  and  less  toward  drugs 
(particularly  the  coal-tar  derivatives). 


FEVERS.  9 

Sudden  Onset. — A  high  fever,  rapidly  reached,  is  found  in 
tonsillitis,  malaria,  scarlet  fever,  pneumonia,  osteomyelitis, 
and  gastrointestinal  disturbances  in  children. 

The  incubation  period  varies  greatly  in  the  different  diseases, 
as  may  be  seen  from  the  following  table  modified  from  that 
given  by  G.  H.  Roger  in  his  "Introduction  to  the  Study  of 
Medicine:" 


Minimum 


Maximum 


•    Average 


Anthrax |  i  day    . 

Bubonic  plague '  2  days 

Chancre  (hard),  see  SyphiHs 

Chancre  (soft)    i  day    . 

Cholera     i  i  day    . 

Diphtheria   I  2  days 

Erysipelas    !  3  hours 

Glanders I  24  hours 


3  days 
7  days 


Gonorrhea 
Hydrophobia 

Influenza    

Malaria     

Measles     

Mumps 

Recurrent  fever  .  . 
Rubella,  Rubeola, 
Rotheln 

Scarlatina 

Small-pox 

Syphilis 

Tetanus    

Typhoid  fever.  .  .  . 

Typhus     

Vaccinia     

Varicella 

Whooping  cough  . 
Yellow  fever    .  .  .  . 


(?)  to  2  days  . 
13  days    

1  day    

99  hours 

4  days    

7  days    

86  hours 

5  days    

7  hours 

7  days    

10  days    

2  hours 

2  days  (?) 
o(?) 

2  days    

13  days    

2  days    

2  days    


3  days    

6  days    

15  days    

22  days    

3  months   

I  to  several  weeks . 

18  mos.  to  3  yrs.  (?) 

5  days    

Several  months  .  .  . 

14  days  

30  days  

8  days  

21  days  

7  weeks  

15  days  

so  days  

35  days  

2 1  days  

23  days  

7  days  

19  days   

8  days  

6  days  


2  days. 

4  to  6  days. 

1  to  2  days. 

2  to  4  days. 

2  days. 

4  to  6  days. 

3  to  5  days. 
3  to  s  days. 
20  to  60  days. 
3  to  4  days. 

6  to  10  days. 
9  days. 
IS  days. 

5  to  6  days 

18  days. 

2  to  5  days. 

12  days. 

20  to  30  days. 

2  to  3  days. 
14  days. 

12  days. 

3  days. 

14  to  IS  days. 
8  days  . 
3  to  4  days. 


Eruptive  Fevers. — Certain  fevers  are  attended  by  eruption, 
the  date  of  the  appearance  of  which  is  of  extreme  importance 
in  the  diagnosis. 

The  eruptive  fevers,  or  diseases  that  have  a  characteristic 
rash  are  called  the  Exanthemata.  The  following  table  (ab- 
breviated from  one  in  Gould  and  Pete's  Cyclopedia  of  Medi- 
cine) will  be  of  service: 


to 


FEVERS. 


< 
m 

H 

< 

X 

o 

w 

m 
<; 


d 
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B 

P 
C 

4) 

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oi 

go 

C 
C 
oi 

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one  week. 

^  2 

^   O 

m 

c 

03 
1-1 

+3 
bo 

00 

o 
lo 

is  tn- 
tn  >> 
3  oi 

c5^ 

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days. 

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05 
o 
o 

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c 
o: 
ft 

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13  O 

rC      > 

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.-13 

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oi  ^ 

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tn 

tn 

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03 

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0  0 
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tn  tn 
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03 

13 
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— it:  « 

o3        a 

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o 
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(U 

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go 

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c 

a 

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Q 

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i     . 
tn  en 
O  +J 

tn 
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tH      O 

a 

H- 1 

CO  S-, 

ri3      03 

03  i! 

aS 

•  -  u 
tn  o 

o'o 
ao 
"5  .. 

tn 

oi  2;  13 
03  4->   <u 
gtn. 

If 

0, 

_o 
t? 

0, 

> 

t/- 

C 

c 

l- 

a 

C 

l-H 

, 

u 
C 

1: 
0, 

Time  or  appearance 
of  eruption. 

c 
■t-j 

1- 

> 

cd 

r 

tr 

u 

C 

oc 

r 

XT 
U 

3 
0 

r 

it 

,C|   O 

3  2-^ 

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1-. 

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6 
B 

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. 

cd 

C 

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' 

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03 
> 
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tn 

a 
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> 

0 

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u 

1 

SIMPLE    CONTINUED    FEVER.  II 

Immunity. — Some  of  the  infectious  fevers  confer  protection 
against  subsequent  attacks;  among  which  may  be  mentioned 
German  measles,  measles,  mumps,  scarlet  fever,  small-pox,  ty- 
phus, varicella,  and  yellow  fever.  Second  attacks  occasionally 
occur  in  measles,  small-pox,  typhoid,  and  typhus  fever.  The 
rest   of   the   fevers   seem   devoid   of   immunizing   properties. 

Jaundice. — Occasionally  the  disturbance  of  metabolism  and 
tissue  change  are  so  great  in  fever  as  to  interfere  with  the 
functional  activity  of  the  liver  and  a  generalized  yellowish 
discoloration  or  jaundice  results.  This  is  common  in  acute 
yellow  atrophy  of  the  liver,  yellow  fever,  relapsing  fever,  and 
intermittent  malaria. 

SIMPLE  CONTINUED  FEVER. 

Synonyms. — Febricula;   ephemeral  fever. 

Definition.— An  acute,  non-contagious,  febrile  disease  of 
short  duration  and  mild  type  unattended  by  characteristic 
lesions.  When  the  condition  lasts  only  one  day  it  is  called 
ephemeral  fever;  the  other  names  are  applied  to  cases  of 
longer  duration. 

Etiology. — It  is  most  common  in  childhood  and  ma}^  arise 
from  gastrointestinal  disorders,  mental  or  physical  fatigue, 
excitement,  emotion,  or  exposure  to  high  degrees  of  heat  or 
cold. 

Symptoms. — The  onset  is  sudden  and  may  be  ushered  in 
with  nausea,  vomiting,  convulsions,  or  a  chill.  It  is  attended 
by  great  lassitude.  The  temperature  rises  suddenly  to  102° 
or  103°  F.  and  is  accompanied  by  headache,  increased  respira- 
tion, quick  tense  pulse,  dryness  of  the  skin,  thirst,  coated 
tongue,  constipation,  and  scanty,  high-colored  urine  of  in- 
creased specific  gravity.  Delirium  may  be  present  in  some 
cases.  There  is  no  constant  or  characteristic  eruption  but 
herpes  are  often  observed  on  the  lips.  The  duration  of  the 
affection  varies  from  twenty-four  hours  to  six  or  seven  days 
and  may  terminate  by  crisis  or  lysis.     Convalescence  is  rapid. 

Diagnosis. — The  history  is  always  of  value  in  differentiat- 


12  INFLUENZA. 

ing  this  condition  from  other  somewhat  similar  affections, 
as  most  cases  are  observed  in  children  as  the  result  of 
mild  gastrointestinal  trouble.  Local  inflammatory  conditions 
should  be  carefully  excluded  by  a  thorough  examination. 
The  concomitant  symptoms  will  aid  in  distinguishing  it  from 
atypical  cases  of  typhoid  fever;  while  in  malaria,  the  peri- 
odicity and  the  presence  of  the  plasmodium  will  settle  the 
diagnosis. 

Prognosis. — Uneventful  recovery  is  the  rule. 

Treatment. — Rest  in  bed  and  a  liquid  or  semisolid  diet  are 
essential.  If  due  to  gastrointestinal  disturbances  a  powder 
containing  calomel,  gr.  i/6  (o.oi  gm.),  sodium  bicarbonate, 
gr.  ii  (0.13  gm.),  and  powdered  ipecac,  gr.  1/12  (0.005  g^"^-). 
should  be-  taken  every  two  hours  until  twelve  have  been  con- 
sumed after  which  an  enema  or  a  seidlitz  powder  should  be 
given.  The  body  surface  should  be  sponged,  and  diaphor- 
etics and  diuretics  should  be  administered.  Acetanilid,  gr.  ii 
to  V  (0.13  to  0.3  gm.),  may  be  given  every  two  or  three  hours 
in  cases  unassociated  with  digestive  disorders.  Tincture  of 
aconite  may  be  employed  when  the  pulse  is  quick.  When 
the  nervous  symptoms  and  insomnia  are  marked  potassium 
bromid  or  trional  may  be  used.  During  convalescence  qui- 
nin  and  tincture  of  nux  vomica  are  of  great  value. 


INFLUENZA. 

Synonyms. — La  grippe;  grip;  epidemic  catarrh;  catarrhal 
fever. 

Definition. — An  acute,  infectious  and  contagious  disease; 
sporadic,  epidemic,  and  pandemic;  associated  with  catarrhal 
inflammation  of  the  respiratory  and  sometimes  of  the  digestive 
tract,  muscular  pain,  disturbances  of  the  nervous  system  and 
debility  out  of  all  proportion  to  the  intensity  of  the  fever  and 
the  catarrhal  processes,  and  a  tendency  toward  serious  com- 
plications and  sequels.  There  are  no  characteristic  anatomic 
lesions. 


INFLUENZA.  1 3 

The  disease  was  almost  unknown  until  the  appearance  of 
the  pandemic  in  the  winter  of  1889-90. 

Causes. — The  affection  is  induced  by  an  extremely  small, 
non-motile  microorganism,  the  bacillus  of  Pfetffer  which  is 
readily  obtained  from  the  sputum.  The  manner  in  which 
it  produces  the  disease  is  not  well  understood.  One  attack 
seems  to  predispose  to  subsequent  attacks.  It  usually  occurs 
in  epidemics  along  the  lines  of  traffic. 

Symptoms. — There  may  be  an  incubation  period  of  a  few 
days,  but  often  the  onset  is  sudden  with  a  chill  or  chilliness 
followed  by  fever,  the  temperature  reaching  101°  to  103°  F., 
a  quick,  compressible  pulse,  severe  shooting  pains  in  the 
eyes  and  forehead,  and  neuralgic  pains  in  the  joints  and  mus- 
cles. These  symptoms  are  followed  by  chilliness  along  the 
spine,  pain  in  the  throat,  hoarseness,  deafness,  coryza.  sneez- 
ing, injected  and  watery  eyes,  and  dry  irritative  cough  The 
tongue  is  usually  furred  and  anexoria,  nausea,  epigastric  dis- 
tress, vomiting,  and  sometimes  diarrhea  are  present.  Depres- 
sion and  debility  disproportionate  to  the  symptoms  are  almost 
constant.  The  symptoms  usually  group  themselves  so  that 
an  attack  may  be  said  to  be  of  the  catarrhal,  gastrointestinal, 
or  nervous  type  according  to  which  group  predominates. 
Any  of  these  symptoms  may  be  greatly  exaggerated,  causing 
the  affection  to  simulate  other  febrile  diseases.  In  mild  cases 
the  temperature  falls  on  the  fourth  or  fifth  day  by  crisis,  and 
convalescence  promptly  begins  in  the  absence  of  complications. 
Complications  and  relapses  are  common  and  frequently  prolong 
the  disease  over  several  weeks. 

Complications  and  Sequels. — Inflammatory  conditions  of 
the  respiratory  tract,  especially  pneumonia,  are  the  most 
frequent.  Hyperpyrexia,  cerebrospinal  meningitis,  pericarditis, 
and  cardiac  neuroses  are  also  encountered  as  complications. 
As  sequels  may  be  mentioned  phthisis,  mania,  confu- 
sional  insanity,  melancholia,  neurasthenia,  insomnia,  neuritis, 
neuralgia,  persistent  headache,  and  lymphatic  enlargements. 

Diagnosis. — In  order  to  recognize  influenza,  the  sudden 
onset,     marked    general    catarrh,    the    severe    pains    and    pro- 


14  INFLUENZA. 

nounced  prostration  should  be  borne  in  mind.  In  the  pres- 
ence of  an  epidemic  there  will  be  but  little  difficulty.  Isolated 
cases  may  be  mistaken  for  acute  bronchitis,  typhoid  fever, 
dengue,  or  cerebrospinal  fever,  but  the  presence  of  the  cardinal 
symptoms  will  serve  to  make  the  distinction. 

Prognosis. — Recovery  is  the  rule  in  young  and  healthy 
adults  and  may  be  looked  for  in  uncomplicated  cases.  In 
either  extreme  of  life  the  disease  becomes  proportionately 
more  grave.  The  presence  of  chronic  organic  diseases,  such 
as  Bright's  disease,  fatty  heart,  emphysema,  and  tubercu- 
losis, influence  the  aflfection  unfavorably.  Many  die  of  the 
complications. 

Treatment. — Supportive  measures  are  indicated  from  the 
start  to  combat  the  marked  exhaustion.  The  patient  should 
be  placed  at  absolute  rest  in  bed  and  restricted  to  a  semi- 
solid diet.  All  the  secretions  should  be  disinfected.  The 
bowel  movements  should  be  kept  soluble,  preferably  by  the 
administration  of  fractional  doses  of  calomel.  In  the  early 
stages  a  hot  foot-bath  or  a  hot  tub-bath  together  with  the 
administration  of  sweet  spirits  of  niter  or  the  solution  of  am- 
monium acetate  may  often  be  of  great  benefit. 

The  catarrhal  symptoms  and  pains  are  often  relieved  by 
the  following: 

I^.     Phenacetin gr.  iii  .  2        gm. 

Pulv.  camphorae gr.  i  .065  gm. 

Caffein.  citrat gr.  i  .  065  gm. 

M.  Disp.  in  capsul.  vel  chart.      No.  i. 

S. — To  be  given  every  two  hours  alternated  with   quinin 
sulphate  gr.  ii  (o  .  13). 


Or- 


I^.      Sodii  benzoat 5ii  8.          gm. 

Salol oss.  2 .         gm. 

Phenacetin gr.  xl  2.6       gm. 

Strych.  sulphat gr.  1/5  ,012  gm. 

M.  Disp.  in  chart,  vel  capsul.    No.  xii, 
S. — One  every  three  or  four  hours. 


INFLUENZA.  1 5 

Antipyrin,  salicin  (R.  G.  Curtinj,  and  quinin  sulphate 
when  administered  during  the  very  early  stages  may  serve  to 
abort  the  disease  but  should  be  carefully  guarded  to  avoid 
intensifying  the  depression.  In  neuralgic  cases  the  salicylate 
of  cinchonidin  in  doses  of  gr.  v  (0.32  gm.)  every  four  hours  is 
especially  valuable.  Opium  in  some  form  may  be  necessary 
in  severe  cases  to  relieve  the  pains. 

An  excellent  prescription  is  the  following: 

I^.     Quininae  sulphat gr.  xxxvj  2.25  gm. 

Extr.  aconiti gr.  ijss  .  i6  gm. 

Phenacetin 5  j  4 .  gm. 

Pulv.  Dover g^-  xij  .75  gm. 

M.  Ft.  in  capsul.  No.  xxiv. 

S. — Take  two  every  three  hours. 

The  frequent  inhalation  of  the  vapor  from  a  pint  of  boiling 
water  to  which  foss  (2  c.c.)  of  compound  tincture  of  benzoin 
has  been  added  relieves  the  nasopharyngeal  and  bronchial 
symptoms,  but  should  they  become  troublesome  the  following 
mixture  is  advised: 

I^.     Ammon.  chlorid gr.  x  .65     gm. 

Tr.  hyoscyam tti^"^  ^  •  ^■^■ 

Sjv.  ipecac tt\v  .  3        c.c. 

Spts.  frumenti f  oss.  ...  2  .  c.c. 

Aqnse  chloroformi f  5iss  6 .  c.c. 

M.  S. — To  be  taken  in  water  every  three  or  four  hours. 

The  complication  of  pneumonia  is  best  combated  by  the 
use  of  stimulants  such  as  alcohol  and  strychnin.  The  follow- 
ing prescription  is  also  recommended  (Pepper) : 

I^.      Morphine  sulphat gr.  j  .065  gm. 

Quininae  sulphat ......  .      gr.  xxxv  2.3       gm. 

Strychninag  sulphat gr.  ss  .03'  gm. 

Acid.  phos.  dil f  oii]  12.  c.c. 

Glycerini f  ov  20.  c.c. 

Aquae q.  s.  ad  f  oiij  q.  s.  ad  90  .  c.c. 

M.  S. — A  teaspoonful  four  to  six  times  daily,  in  water. 


1 6  TYPHOID    FEVER. 

Bartholow  advises  the  early  use  of  pilocarpin,  gr.  i/6 
(o.oi  gm.),  repeated  until  its  mild  physiologic  effects  ensue 
when  it  is  substituted  by  duboisin,  gr.  1/300  to  1/200  (0.00022 
to  0.00032  gm.),  twice  daily;  and  for  the  depression  he  employs 
the  officinal  pills  of  the  iodid  of  iron,  one  pill  every  four  hours, 
and  has  the  patient  inhale  one  or  two  drops  of  pyridin  every 
three  or  four  hours. 

During  convalescence  good  food,  and  tonics  such  as  strych- 
nin, syrup  of  the  iodid  of  iron,  quinin,  cod  liver  oil,  etc., 
should  be  freely  given  with  the  view  of  preventing  complica- 
tions and  sequels  which,  when  they  do  occur,  receive  the  same 
treatment  as  if  they  were  independent  affections. 


TYPHOID  FEVER. 

Synonyms. — Enteric  fever;  gastric  fever;  nervous  fever; 
enteromesenteric    fever;    abdominal    typhus;    autumnal    fever. 

Definition. — An  acute,  infectious,  febrile  affection,  due  to 
a  special  poison;  characterized  by  insidious  prodromes,  ep- 
istaxis,  dull  headache  followed  by  stupor  and  delirium,  red 
tongue,  becoming  dry,  brown,  and  cracked,  abdominal  ten- 
derness, early  diarrhea  and  tympany,  and  a  peculiar  eruption 
upon  the  abdomen;  rapid  prostration  and  slow  convalescence; 
a  constant  lesion  of  Peyer's  patches,  the  mesenteric  glands, 
and  the  spleen  with  enlargement  of  the  latter. 

Causes. — The  predisposing  causes  are  early  adult  life  .(fifteen 
to  thirty  years),  late  summer  and  early  fall  months,  fatigue,  and 
individual  susceptibility. 

The  exciting  cause  is  the  typhoid  bacillus  or  bacillus  of 
Eberth,  which  is  found  in  the  lesions,  blood,  stools,  urine,  and 
sputum  of  typhoid  patients.  The  poison  gains  entrance  to 
the  system  through  the  alimentary  tract  by  means  of  con- 
taminated water,  milk,  ice,  meat,  oysters,  celery,  lettuce,  or 
similar  substances.  Carelessness  in  disposing  of  the  excreta 
is  a  frequent  cause  but  flies  may  aid  in  the  dissemination  of  the 
poison.     The     atmosphere     is    never     impregnated    with     the 


TYPHOID   FEVER.  1 7 

fever  germ.  "Food,  fingers  and  flies"  are  the  chief  means 
of  local  propagation. 

Pathologic  Anatomy. — The  anatomic  lesions  of  typhoid 
fever  are  invariably  present  and  are  characteristic.  They 
consist  in  changes  in  Peyer's  patches,  solitary  glands  and  mes- 
enteric glands,  and  may  be  divided  into  four  stages : 

First.  Stage  of  infiltration  or  swelling  due  to  excessive  pro- 
liferation of  the  cellular  elements  and  infiltration  which  also 
involves  the  surrounding  mucous  membrane.  Peyer's  patches 
become  pale,  thickened,  hardened,  and  elevated  above  the 
mucous  membrane.  These  changes  may  affect  only  three  or 
four  of  the  glands  or  may  involve  the  entire  number.  They 
have  been  noted  as  early  as  the  second  day. 

Second.  Stage  of  necrosis,  softening,  or  sloughing  of  the 
diseased  structures.  The  exudate  may  be  absorbed  or  it  may 
undergo  necrotic  changes  and  be  discharged  leaving  an  oval 
ulcer  with  an  irregular  margin  having  for  its  base  the  sub- 
mucous, muscular,  or  peritoneal  coat  of  the  intestine.  These 
changes  take  place  in  the  second  or  third  week  of  the  disease. 

Third.  Stage  of  ulceration,  in  which  the  separation  of  the 
sloughing  and  necrotic  areas  is  complete  leaving  ulcers  of  vari- 
ous sizes  at  the  sites  of  the  Peyer's  patches  and  solitary  glands. 
This  process  belongs  usually  to  the  third  week  of  the  disease. 
These  ulcers  of  the  intestine  are  characteristic,  and  can  be 
differentiated  from  tubercular  ulcers  in  the  same  situation,  as 
follows : 

In  the  typhoid  ulcer  (i)  the  main  axis  of  the  ulcer  lies  par- 
allel with  that  of  the  intestine;  (2)  it  lies  opposite  to  the  mes- 
enteric attachment;  (3)  it  has  smooth  floor  and  undermined 
edges ;  (4)  it  commonly  leads  to  perforation.  In  tubercular 
ulcer  (i)  the  long  axis  of  the  ulcer  lies  at  right  angles  to  that  of 
the  intestine;  (2)  it  is  not  necessarily  situated  opposite  the 
mesenteric  attachment;  (3)  its  floor  is  not  smooth  nor  are 
its  edges  undermined,'  but  rather  funnel-shaped  and  irregular; 
(4)  it  is  not  apt  to  perforate,  but  it  does  not  tend  to  heal, 
rather  to  spread. 

Fourth.     Stage  of  cicatrization,  in  which  the  ulcerated  area 


1 8  TYPHOID   FEVER. 

is  replaced  by  scar-tissue.  The  gland-structure  is  never 
regenerated. 

In  unfavorable  cases  perforation  is  liable  to  occur  at  this 
stage.  Under  ordinary  circumstances  this  stage  is  associated 
with  the  fourth  week. 

The  mesenteric  glands  and  spleen  undergo  changes  similar  to 
those  in  Peyer's  patches,  namely,  infiltration,  enlargement,  and 
softening,  but  seldom  if  ever  rupture  or  ulcerate.  The  spleen 
usually  begins  to  enlarge  in  the  middle  of  the  first  week,  the 
enlargement  reaching  its  height  at  the  end  of  the  second  week. 

The  mucous  membrane  of  the  entire  intestinal  tract  is  the 
seat  of  catarrhal  changes  and  a  similar  condition  is  common 
in  the  respiratory  tract.  The  heart,  liver,  and  kidneys  are 
affected  with  parenchymatous  or  granular  changes. 

In  mild  cases  the  entire  exudate  in  the  lymphatic  aggre- 
gations is  absorbed  without  ulceration  and  in  very  rare  in- 
stances the  disease  may  manifest  itself  as  a  general  septic 
infection  without  any  anatomic  lesions  in  the  intestine. 

Symptoms.  Stage  of  Prodromes. — The  onset  is  insidious, 
with  a  feeling  of  general  malaise,  vertigo,  headache,  particu- 
larly occipital  pain,  disordered  digestion,  disturbed  sleep,  ep- 
istaxis,  depression,  and  muscular  weakness,  followed  by  a 
chill  or  chillness,  the  patient  being  unable  to  designate  the 
day  on  which  the  symptoms  began.  In  rare  instances,  the 
disease  begins  abruptly  with  a  chill,  followed  by  a  high  fever; 
this  is  particularly  the  case  in  malarial  districts. 

The  exact  duration  of  these  premonitory  symptoms  is  not 
known,  and  may  be  said  to  vary  from  a  few  days  to  two  or 
more  weeks. 

First  week,  dates  from  the  onset  of  the  fever,  when  there 
are  present  increasing  temperature,  frequent  pulse,  headache, 
listlessness,  the  eyes  closed  as  if  asleep,  coated  tongue,  nau- 
sea, diarrhea  (there  may  be  constipation),  the  abdomen  mod- 
erately distended  and,  upon  pressure  in  the  right  iliac  fossa, 
gurgling  sounds  and  tenderness.  Upon  the  seventh  day  a 
few  reddish  spots  resembling  flea  bites  appear  upon  the  abdo- 
men, chest,  or  back. 


TYPHOID   FEVER. 


19 


Second  Week.  The  foregoing  symptoms  are  exaggerated; 
fever  is  now  continuous,  with  a  frequent,  compressible,  di- 
crotic pulse,  tympanitic,  tender  abdomen,  gurgling  in  the 
right  iliac  fossa,  nocturnal  delirium,  severe  and  constant  head- 
ache,   often    stupor,    a    short    cough    with    distinct    bronchial 


Fig.  I. — Clinical  chart  of  enteric  fever  of  four  weeks  duration,  without  complications, 
which  shows  the  temperature  curve  as  uninfluenced  by  treatment.  {From  Wilcox's  Fever 
Nursing.) 


rales  on  ausculation,  irregular  muscular  contractions  {sub- 
sultus  tendinum),  sordes  upon  the  teeth  and  lips,  the  torigue 
losing  its  coating  and  becoming  more  or  less  dry,  the  diarrhea 
continuing.  During  this  stage  deafness  frequently  develops, 
often  increasing  until  profound,  and  persisting  in  convales- 
cence. Disturbances  of  vision  are  common  in  pronounced 
cases.      The  spleen  is  increased  in  size. 


20  TYPHOID   FEVER. 

Third  Week.  Fever  changes  from  continuous  to  remit- 
tent; the  evening  exacerbations  continue  as  high  as  the  pre- 
ceding week,  the  morning  fall  growing  more  decided  each  day, 
but  all  the  other  symptoms  remain  about  the  same  until  near 
the  end  of  the  week,   when  a  marked  amelioration  begins. 

In  a  fair  proportion  of  cases  all  the  symptoms  grow  worse 
toward  the  end  of  the  second  or  during  the  third  week.  The 
prostration  is  extreme,  the  stupor  so  marked  that  it  is  hardly 
possible  to  rouse  the  patient,  the  tongue  is  dry,  hard,  cracked, 
and  covered  with  a  brown  crust;  sordes  collect  on  the  gums 
and  teeth;  the  lips  are  cracked;  the  pulse  is  rapid  and  feeble;  the 
respirations  shallow  and  quickened,  and  there  may  be  retention 
of  urine,  which  may  contain  albumin.  The  stools  are  often 
voided  involuntarily,  and  bed-sores  develop,  this  condition 
terminating  in  death  or  passing  thus  into  the  fourth  week. 

Fourth  Week.  The  fever  decidedly  remits,  and  is  almost  nor- 
mal in  the  morning ;  the  pulse  becomes  less  frequent  and  more 
full,  tongue  gradually  becoming  clean;  the  abdomen  lessens 
in  size,  the  diarrhea  ceases,  the  patient  passing  into  a  slow 
convalescence,  greatly  emaci'ated,  which  convalescence  may 
continue  for  several  weeks. 

Analysis  of  Symptoms. — The  temperature  record  of  typhoid 
fever  is  characteristic.  The  fever  on  the  morning  of  the 
first  day  may  be  stated  as  98.5°  F.,  evening  100.5°;  second 
morning  99.5°,  evening  101.5°;  third  morning  100.5°,  even- 
ing 102.5°;  fotirth  morning  101,5°,  evening  103.5°;  fifth  even- 
ing 104.5°.  From  that  time  until  the  end  of  the  second  week 
the  evening  temperature  ranges  between  103°  and  105°,  the 
morning  temperature  being  a  degree  or  more  lower.  During 
the  second  or  third  week  hyperpyrexia,  or  fever  above  105°  F., 
may  develop,  and  adds  to  the  gravity  of  the  attack.  A  high 
teniperature  during  the  third  and  fourth  week  is  of  grave  import. 
Temperatures  of  1 06°- 107°  with  recovery  have  been  reported 
but  are  extremely  rare. 

Afebrile  cases  of  typhoid  fever  are  occasionally  observed; 
all  other  symptoms  (including  the  prostration)  excepting  the 
step-like  temperature,  being  present. 


TYPHOID   FEVER.  21 

Diarrhea  is  the  principal  intestinal  symptom;  if  absent, 
the  lesion  may  be  slight.  The  stools  are  at  first  dark,  but 
early  in  the  second  week  they  become  fluid,  offensive,  ochre- 
yellow  in  color,  resembling  "peasoup,"  and  may  be  streaked 
with  blood.  They  number  from  three  to  fifteen  during  the 
twenty-four  hours. 

Constipation    occurs    more    frequently    than    is    supposed. 

The  urine  has  the  ordinary  febrile  characters.  Typhoid 
bacilli  are  demonstrable  in  about  20  per  cent,  of  cases.  Re- 
tention is  common.  Ehrlich  describes  a  reaction  (diazo- 
reaction)  which  he  believes  is  rarely  met  with  save  in  typhoid 
fever;  but  it  has  been  found  in  a  number  of  other  conditions, 
particularly  those  having  gastrointestinal  symptoms.  For  the 
performance  of  this  test  see  page  346, 

The  eruption  is  almost  constant.  It  consists  of  from  five  to 
twenty  small  rose-colored  spots  on  the  abdomen,  chest,  or 
back,  sometimes  on  the  limbs,  appearing  in  crops,  lasting 
about  five  days,  disappearing  on  pressure  and  at  death.  It 
returns  with  relapses.  Eruption  day  varies  from  the  seventh 
to  the  ninth.  Rarely,  spots  of  a  delicate  blue  tint — the 
"taches  bleudtres"  of  French  authors — are  observed.  Very  oc- 
casionally in  malignant  cases  the  eruption  may  become  hem- 
orrhagic or  petechial  in  character. 

Nervous  symptoms  are  pronounced  headache,  followed  by 
dullness  of  intellect,  passing  into  drowsiness  and  stupor,  with 
great  prostration.  Deafness  is  pronounced.  Sight  is  impaired, 
and  in  grave  cases  double  vision  results.  Delirium,  low  and 
muttering,  generally  pleasant  in  character,  is  nearly  always 
present  in  severe  cases.  Coina  vigil  is  a  grave  symptom,  the 
patient  lying  perfectly  quiet  with  eyes  open,  taking  no  heed 
to  his  surroundings. 

Splenic  enlargement  is  an  almost  constant  clinical  feature. 
A  vertical  dullness  exceeding  two  ribs  and  an  interspace 
signifies  enlargement.  Palpation  is  a  valuable  aid  for  de- 
termining splenic  enlargement. 

Muscular  symptoms  are  developed  late  in  the  second  or 
early  in  the  third  week,  and  consist  of  irregular  contractions, 


2  2  TYPHOID   FEVER. 

carphologia  ( picking  at  the  bedclothes  or  at  imaginary  obj  ects) , 
or  subsultus  tendinum  (see  page  19),  and  are  the  result  of  the 
great  debility.  The  reverse  of  muscular  contractions,  when  the 
patient  lies  perfectly  motionless  in  bed,  attempting  no  muscular 
effort  of  any  kind,  is  a  grave  sign. 

Convalescence  shows  great  debility  and  emaciation,  extreme 
anemia,  and  severe  nervousness,  often  very  protracted.  It 
is  during  convalescence  that  irritability  of  the  heart,  profuse 
night-sweats,   insomnia,   and   in  women  loss   of  hair  occur. 

Complications. — Intestinal  hemorrhage  is  the  most  frequent 
and  at  times  the  most  critical  of  any  of  the  complications  of 
typhoid  fever.  The  hemorrhage  may  occur  any  time  between 
the  fourteenth  and  twentieth  day;  a  sudden  decline  of  the 
temperature  to  the  normal  or  below  frequently  precedes  the 
passage  of  blood  by  stool.  The  hemorrhage  is  due  to  the 
erosion  of  a  vessel  during  the  ulcerative  stage. 

Perforation  makes  the  case  almost  hopeless.  It  is  attended 
by  sudden  localized  pain  and  tenderness,  tympanites,  abrupt 
fall    in    the   temperature,    and  symptoms  of  peritonitis    (q.v.). 

Peritonitis  without  perforation  adds  to  the  gravity,  but  is 
not  necessarily  fatal. 

Lobar  pneuminia,  hypostatic  congestion,  and  bronchitis  are 
frequent  occurrences.  There  are  few  cases  that  do  not  have 
slight  bronchial  cough  from  the  onset.  Albuminuria  and  acute 
nephritis  may  occur,  as  may  also  thrombosis  of  the  femoral 
vein,  usually  the  left.  Bed-sores  are  frequent,  resulting  from 
the  impaired  nutrition,  emaciation,  pressure  over  bony  promi- 
nences, and  uncleanliness. 

Ulceration  of  the  tongue  and  mucous  membrane  of  the 
cheek  is  sometimes  observed. 

Sequelae. — Paralysis — either  mono-  or  paraplegia — may  take 
place,  due  to  an  acute  neuritis.  Post-febrile  insanity  occurs 
more  frequently  after  typhoid  than  any  other  febrile  condition 
except  influenza.  Acute  nephritis  associated  with  edema, 
alopecia,  complete  or  partial,  transverse  markings  of  the  nails, 
and  tuberculosis  may  develop. 

Varieties — Abortive  typhoid  is  that  variety  in  which    conva- 


TYPHOID   FEVER.  23 

lescence  is  established  within  ten  days  or  two  weeks  after  an 
abrupt  onset  with  marked  symptoms.  Mild  typhoid  is  char- 
acterized by  moderate  fever,  shght  diarrhea,  and  few  if  any 
nervous  symptoms.  Ambulant,  or  walking  typhoid,  is  a  mild 
type  in  which  the  symptoms  are  so  slight  as  often  to  be  dis- 
regarded by  the  patient.  Cases  of  this  character  often  ter- 
minate fatally  from  the  very  sudden  occurrence  of  perforation 
and  other  serious  complications.  Typhoid  in  children  is 
nearly  always  marked  by  the  predominance  of  the  nervous 
symptoms. 

Relapses  are  not  uncommon.  The  symptoms  are  nearly  all 
repeated  but  are  less  intense  than  those  of  the  original  attack. 
A  sudden  elevation  of  temperature  during  convalescence 
independent  of  other  symptoms  is  termed  recrudescence  and 
is  due  to  excitement  or  gastrointestinal  disturbances. 

Diagnosis. — The    Widal   Reaction.      Widal    and    others   have 
shown  that  serum  from  the  blood  of  one  ill  with  typhoid  fever, 
if  mixed  with  a  recent  culture,  will  cause  the 
typhoid    bacilli    to    lose    their  motility  and 
gather  in  groups,   the  whole  called  ''clump- 
ing.' '     "  Three  drops  of  blood  are  taken  from 
the  well-washed  aseptic  finger-tip  or  lobe  of 
the  ear,  and  each  lies  by  itself  on  a  sterile 
slide,  passed  through  a  fiame  and  cooled  just 
before  use;    this  slide  may  be  wrapped  in      p^^    ^  _^    ^^.^ 
cotton  and  transported  for  examination  at  giutination  test.  (Widai. 

^  .  .  upper     segment      snows 

the   laboratory.      Here    one    drop   is    mixed  the  freely  moving  germs. 

..,  1  .,  r      ,       •^  ,         ,  1-         The     lower    the    typical 

With  a  large  drop  of  sterile  water  to  redis-   "clumping."     {From 

1  •,  Aj  r  J.1  "j.       rj.1-       Greene's        Medical 

solve  it.  A  drop  from  the  summit  or  this  Diagnosis.) 
is  then  mixed  with  six  drops  of  fresh  broth 
culture  of  the  bacillus  (not  over  twenty-four  hours  old) 
on  a  sterile  slide.  From  this  a  small  drop  of  mingled  culture 
and  blood  is  placed  in  the  middle  of  a  sterile  cover-glass, 
and  this  is  inverted  over  a  steril  hollow-ground  slide  and 
examined.  ...  A  positive  reaction  is  obtained  when  all  the 
bacilli  present  gather  in  one  or  two  masses  or  clumps  and  cease 
their  rapid  movement  inside  of  twenty  minutes." 


24  TYPHOID   PEVER. 

The  reaction  seldom  appears  before  the  seventh  or  eighth 
day  and  may  persist  after  recovery. 

The  Widal  test  is  practically  pathognomonic  and  should 
be  made  a  regular  method  of  examination  in  all  but  the  most 
typical  conditions 

The  characteristic  symptoms  that  serve  to  distinguish  ty- 
phoid fever  from  other  diseases  in  which  depression  is  a  marked 
feature  are  the  Widal  reaction,  the  temperature,  the  eruption, 
a  low  leucocyte  count,  the  diarrhea,  and  the  enlarged  spleen. 

Typhus  fever  is  uncommon  and  the  differential  diagnosis 
of  these  two  diseases  has  now  only  an  academic  (or  examina- 
tional) interest;  see  under  Typhus  Fever,  page  ^2>- 

Enteritis  has  intestinal  derangement  and  an  irregular  fever. 

Peritonitis  is  attended  with  abdominal  symptoms  only, 
with   constipation   and   rapid   early   prostration   and   collapse. 

Acute  miliary  tuberculosis  may  be  mistaken  for  typhoid 
fever.  The  temperature  record  is  more  irregular;  there  is 
no  eruption;  the  pulmonary  symptoms  are  more  pronounced; 
the  abdominal  symptoms  are  less  marked;  tubercles  may  be 
detected  by  the  ophthalmoscope;  and  the  Widal  and  diazo- 
reactions  are  not  obtained  in  tuberculosis. 

Meningitis  resembles  typhoid  fever  somewhat  but  may  be 
distinguished  from  it  by  its  sudden  onset,  marked  cerebral 
manifestations  from  the  very  begininng,  leukocytosis,  the  ab- 
sence of  the  characteristic  symptoms  and  reactions  of  typhoid 
already  given,  and  the  presence  of  meningococci  in  the  cere- 
brospinal fluid  obtained  by  lumbar  puncture,  and  Kernig's  sign. 

In  ulcerative  endocarditis  the  abdominal  tenderness,  the  erup- 
tion and  headache  are  not  common,  the  Widal  test  will  be 
negative,  and   the  fever  is  not  so  peristent  and  characteristic. 

Malaria  may  simulate  typhoid  fever  but  the  blood  ex- 
amination will  serve  to  clear  up  the  diagnosis.  Both  dis- 
eases may  be  present  coincidently  in  the  same  patient;  but  the 
mongrel  affection  typho- malaria,  so-called,  does  not  exist  as 
such. 

Concealed  suppuration  will  be  distinguished  by  the  fever 
chart  and  the  leukocytosis. 


TYPHOID   FEVER.  25 

Prognosis. — A  positive  prognosis  cannot  be  made.  Favor- 
able indications  are  constipation  or  slight  diarrhea,  low  tem- 
perature, and  moderate  delirium.  Unfavorable  symptoms  are 
obstinate  and  severe  diarrhea,  early  high  temperature,  cardiac 
exhaustion,  marked  nervous  symptoms  with  coma  vigil  or 
stupor,  albuminuria,  and  repeated  intestinal  hemorrhages. 

The  prognosis  is  always  more  favorable  in  winter  than  in 
summer. 

When  death  occurs  it  is  usually  during  or  about  the  third 
week,  the  result  of  exhaustion,  cardiac  failure,  or  some  com- 
plication. Children  under  puberty  usually  recover.  More 
women  than  men  die,  although  less  women  have  the  disease. 
Pregnant  women  and  fleshy  people  usually  succumb. 

The  mortality  in  typhoid  fever  in  private  practice  is  about 
one  death  in  twenty;  in  hospital  practice  it  varies  from  one 
death  in  five  to  ten  cases,  although  the  cold- bath  treatment 
has  greatly  reduced  the  hospital  mortality. 

Protective  inoculation  against  typhoid  has  been  tried  with 
gratifying  results;  a  vaccine  prepared  by  Sir  A.  E.  Wright 
being  used  for  the  purpose. 

Antityphoid  serum  has  also  been  used,  but  its  value  is  not 
yet  generally  recognized. 

Typhoid  Carriers. — The  typhoid  bacilli  can  live  in  the  body 
long  after  the  patient  has  recovered,  and  this  fact  explains 
some  outbreaks  of  typhoid  hitherto  of  obscure  origin.  Both 
feces  and  urine  may  be  extremely  active  in  the  dissemination 
Df  the  disease;  and,  with  regard  to  the  urine  alone,  McCrae  says: 
"  The  number  which  may  be  present  is  enormous,  and  billions 
of  bacilli  may  be  excreted  each  day;  if  we  consider  the  length 
of  time  during  which  typhoid  bacilli  may  remain  in  the  urine, 
it  is  no  exaggeration  to  say  that  a  man  may  scatter  infection 
around  the  world." 

Prophylaxis. — Typhoid  fever  is  preventable.  When  the  muni- 
cipal authorities  do  not  consider  it  their  duty  to  supply  pure 
water,  each  household  should  boil  all  water  that  is  to  be  used 
for  drinking  or  for  washing  dishes,  etc. ;  milk  should  be  boiled 
also;  and  no  ice  should  be  put  in  water  or  other  drink  or  food; 


26  TYPHOID    FEVER. 

flies  should  be  kept  out  of  the  house  as  far  as  possible,  by  means 
of  screens  or  otherwise ;  all  discharges  from  the  sick  person  must 
be  disinfected;  all  utensils,  dishes,  etc.,  used  by  the  patient  must 
be  thoroughly  cleansed  and  boiled  every  day;  soiled  linen 
must  be  soaked  in  a  disinfectant  solution  before  being  washed; 
after  each  attendance  on  a  patient  physicians,  nurses,  and 
others  should  wash  their  hands  in  a  disinfectant;  thorough 
sterilization  of  all  bedding,  etc.,  must  be  performed  after  the 
disease  is  over. 

Treatment. — The  patient  should  be  placed  immediately 
in  bed  in  a  quiet,  well- ventilated  room  having  an  average 
temperature  of  65°  F.  Intelligent  nursing  is  indispensable. 
The  manner  in  which  the  disease  is  disseminated  necessitates 
the  most  scrupulous  cleanliness  of  the  patient,  the  bedding,  and 
the  various  sick-room  requisites.  The  bed-pan  should  be 
employed  through  the  entire  course  of  the  disease  and  the 
excreta  may  be  rendered  inocuous  by  being  passed  into  twice 
their  (expected)  volume  of  chlorinated  lime  (i  per  cent,  so- 
lution) or  carbolic  acid  (5  per  cent,  solution)  and  allowing 
the  mixture  to  remain  in  a  closed  vessel  for  two  or  three  hours 
before  being  finally  disposed  of  through  the  sewer  or  by  being 
buried.  Bed-linen,  or  other  clothing,  that  may  have  become 
contaminated  should  be  disinfected  by  boiling. 

The  diet  should  be  liquid  and  should  be  given  in  small  quan- 
tities at  intervals  of  two  or  three  hours.  Diluted  milk,  broths, 
soups,  white  of  egg,  coffee,  tea,  buttermilk,  junket,  albumin 
water,  and  similar  foods  are  permissible,  but  milk  is  un- 
doubtedly the  best.  The  appearance  of  curds  in  the  stools 
indicates  that  the  quantity  of  milk  given  is  in  excess. 

Usually  it  is  best  to  dilute  the  milk  with  water,  adding  a 
small  quantity  of  lime  water,  or  to  administer  it  mixed  with 
some  carbonated  water.  The  average  quantity  of  milk  to  be 
given  at  one  time  is  about  5  ounces.  To  allay  the  thirst,  cool 
water  may  be  given  in  small  quantities  at  a  time;  the  patient 
requires  much  water.  Washing  the  tongue,  lips,  and  mouth 
are  also  effective  in  this  respect.  Prostration  is  avoided  to  a 
great  extent  by  regular  feeding  every  two  hours,  but  should  the 


TYPHOID    FEVER.  27 

heart  begin  to  weaken  and  the  pulse  become  soft,  whiskey  or 
brandy,  in  half-ounce  doses  every  three  hours,  should  be  admin- 
istered, preferably  with  milk  so  as  to  aid  in  the  digestive  process. 
The  periods  of  nourishment  and  stimulation  should  be  the  same 
if  possible  and  should  not  be  interfered  with  by  sleep.  Just  now 
there  is  a  tendency  to  grant  a  more  liberal  diet  than  was 
formerly  advised,  but  the  practitioner  should  remember  that 
it  is  easy  to  overfeed  a  typhoid  patient,  and  that  in  severe 
cases  the  digestive  functions  are  in  abeyance.  The  inclusion 
of  solid  foods  in  the  dietary  should  not  be  considered  until 
the  temperature  has  remained  normal  for  at  least  one  week. 

The  reduction  of  temperature  is  perhaps  the  most  impor- 
tant indica,tion  in  the  management  of  this  disease.  This  is 
best  accomplished  by  hydrotherapy.  Cold  sponging  with 
water,  or  alcohol  and  water,  is  often  of  value  in  mild  cases  and 
to  be  effective  the  surface  should  be  left  very  wet,  being  care- 
ful not  to  expose  too  great  a  portion  of  the  body-surface  at 
a  time.  The  cold  pack  is  of  value  in  cases  attended  by  rather 
high  temperatures  (104°  to  105°  F.)  and  is  employed  when 
for  any  reason  the  tub-bath  is  impracticable.  The  bed  should 
be  protected  by  a  rubber  cloth,  and  the  patient,  with  his 
clothing  removed,  should  be  wrapped  in  a  sheet  wrung  out  of 
cold  water.  The  surface  should  be  rubbed  briskly  through  the 
sheet,'  and  from  time  to  time  cold  water  is  freely  sprinkled  over 
the  sheet.  Friction  must  be  continued  during  the  pack,  and  ice 
cloths  or  cap  placed  on  the  head.  The  duration  of  the  cold  pack 
is  determined  by  the  temperature  and  the  reaction  powers  of  the 
patient.  Collapse  may  be  avoided  by  the  administration  of 
whiskey  or  brandy,  or  the  hypodermic  injection  of  strychnin 
before  or  after  the  pack  according  to  the  patient's  condition. 

The  cold  hath,  after  the  method  of  Brand,  or  "tubbing," 
has  proven  most  prompt  and  decided  for  reducing  temperature. 
It  consists  in  the  systematic  employment  of  general  cold 
baths,  with  frictions,  whenever  the  temperature  reaches 
102.2°  F.  As  often  as  the  temperature,  taken  every  three 
hours  in  the  mouth  or  rectum,  is  over  102.2°  F.  the  patient 
receives  a  bath  lasting  fifteen  or  twenty  minutes.     He  wears 


28  TYPHOID   FEVER. 

a  thin  muslin  garment  or  is  wrapped  in  a  sheet;  he  is  given 
a  stimulant  and  carefully  lifted  into  the  bath  of  65°  or  7o°F., 
some  cold  water  being  poured  over  his  head  and  shoulders 
to  lessen  the  shock;  the  head  rests  on  an  air  pillow,  the  body 
submerged  to  the  neck.  During  the  whole  period  oj  the  hath 
the  patient  must  he  hriskly  rubbed.  The  friction  and  affusion 
are  of  value  in  preventing  chill  and  cyanosis.  After  the  bath 
the  wet  linen  is  quickly  removed  and  the  patient  placed  in 
bed,  wrapped  in  a  dry  sheet,  and  covered  with  a  blanket. 
A  stimulant  is  again  given  after  the  bath,  and  if  there  is  any 
tendency  to  cyanosis  or  heart  failure,  a  hypodermic  injection  of 
strychnin.  The  temperature  is  taken  after  the  patient  is  placed 
in  bed  and  again  in  half  to  three-quarters  of  an  hour,  and  if 
not  then  102°  F.,  is  not  again  taken  for  three  hours.  Not  more 
than  eight  such  baths  should  be  given  in  twenty-four  hours. 
The  good  effects  of  the  bath  are  seen  in  a  reduction  of  temper- 
ature, clearer  intellect,  and  lessening  stupor  and  muscular 
twitching.  Sleep  usually  follows  a  bath,  with  a  general 
stimulating  effect   upon   the   heart   and   the   nervous   system. 

Contraindications  to  the  Brand  bath  are  hemorrhage,  per- 
foration, or  peritonitis;  extreme  age  and  weakness;  pleurisy 
or  pneumonia;  when  the  bath  causes  intense  cyanosis  or  much 
dyspnea  or  coughing. 

The  various  antipyretic  drugs,  such  as  antipyrin,  acetanilid, 
phenacetin,  etc.,  while  successful  in  reducing  temperature, 
should  never  be  substituted  for  the  bath  treatment  as  they  add 
to  the  already  intense  exhaustion.  Quinin  sulphate  in  small 
doses  is  of  value  in  that  it  tends  to  lower  the  fever  and  at 
the  same  time  is  tonic  and  more  or  less  stimulating.  The 
quinin  should  be  dissolved  in  citric  acid  and  given  as  an 
effervescent  draught  by  the  addition  of  an  alkaline  mixture, 
when  doses  of  2  or  3  gr.  will  be  found  to  have  a  decided  an- 
tipyretic influence. 

Diarrhea  should  not  be  checked  unless  it  exceeds  three  or 
four  stools  in  twenty-four  hours,  when  the  following  may  be 
used: 


Or- 


TYPHOID   FEVER.  29 

I^.      Bismuth,  subnitrat gr,  xx  1.3  gm. 

Acid  carbol n^j  .06  c.c. 

Tinct.  opii  deodorat TT^viij  o.  5  c.c. 

Mucil.  acaciae 5j  4 .  c.c. 

Aquae f  3iij  1 2 .  c.c. 

M.   S. — Every  three  or  four  hours. 

I^.      Cupri  sulphat gr.  1/6  .011  gm. 

Extracti  opii gr.1/4  .016  gm. 

M.   S. — In  pill,  every  four  hours. 

At  the  onset  of  a  suspected  case  of  typhoid  fever,  when  there 
are  present  coated  tongue,  fetid  breath,  anorexia,  chilliness 
followed  by  feyerishness  or  fever,  nervousness,  costiveness 
or  frequent  tenesmic  stools,  and  general  soreness  associated 
with  mental  unrest  and  headache,  excellent  results  follow 
the  use  of  the  following  combination: 

I^.     Hydrargjrri  chlor,  mit. .  .  gr.  viij  .52     gm. 

Sodii  bicarbonatis gr.  xv  i .         gm. 

Pulv.  ipecacuanhae gr.  ij  .  13     gm. 

Salol gr.  XV  i .         gm. 

M.  Ft.  chart.  No.  xv. 

S. — One   powder    every  three   hours   until   decided   bowel 
action. 

Or— 

I^.     Acid,  sulph.  aromat tti^"^  i  •         c.c. 

Tinct.  opii  deodorat n^x  .6       c.c. 

M.  S. — In  water,  every  three  hours. 

Constipation  in  the  course  of  the  disease  is  best  relieved 
by  enemas,  or  by  calomel  in  divided  doses. 

Tympanites  may  be  relieved  by  the  application  of  cold  com- 
presses, an  ice-bag,  or  a  turpentine  stupe  to  the  abdomen. 
In  extreme  cases  the  introduction  of  a  soft-rubber  catheter 
high  up  in  the  rectum  will  afford  relief.  If  the  tympany  is 
associated  with  constipation,  ten  minims  of  oil  of  turpentine 
and   fifteen    minims   of    castor   oil   in   emulsion,    administered 


30  TYPHOID    FEVER. 

every  three  or  four  hours,  will  prove  very  beneficial.  The 
quantity  of  food  should  be  lessened  in  many  cases  as  the 
distention   is   often   due   to   fermentation   of   undigested   food. 

Headache  when  excessive  may  be  relieved  by  the  application 
of  cold  to  the  head  and  mustard  to  the  neck  and  by  foot- 
baths. Morphin  and  atropin  hypodermically  may  be  required. 
Leeches  are  rarely  necessary. 

Delirium  is  to  a  large  extent  prevented  by  combating  the 
general  exhaustion.  The  use  of  stimulants  and  hydrotherapy 
control  it  in  most  cases,  but  camphor,  musk,  or  morphin 
may  be  required. 

Insomnia  is  sometimes  a  very  troublesome  symptom  and 
necessitates  the  employment  of  trional,  sodium  bromid,  or 
even  morphin  (or  codein). 

Cystitis  may  occur  in  typhoid  fever  and  should  be  care- 
fully guarded  against  by  daily  examination  over  the  bladder, 
and  irrigation  with  sterile  boric  acid  solution  on  the  first 
signs  of  vesical  irritation. 

Intestinal  hemorrhage  indicates  absolute  rest  and  suspension 
of  cold  bathing.  The  foot  of  the  bed  should  be  slightly  ele- 
vated and  an  ice-bag  placed  over  the  right  iliac  region.  Mor- 
phin, gr.  1/4,  should  be  given  hypodermically  at  once.  Fluid- 
extract  of  ergot,  f5i  (4  c.c),  Monsel's  solution,  vc\y  to  x  (0.3 
to  0.6  gm.)  or  oil  of  turpine,  tt^x  (0.6  c.c),  should  be  adminis- 
tered every  two  hours.  The  quantity  of  food  should  be 
reduced  to  the  minimum  and  in  some  cases  feeding  should  be 
suspended  for  twelve  hours  or  more. 

Perforation  and  peritonitis  are  the  most  serious  complications, 
and  demand  the  immediate  services  of  a  competent  surgeon 
as  soon  as  detected.  The  early  operations  are  attended 
with  the  best  results,  and  delay  in  operating  is  far  more 
dangerous  than  the  operation  itself. 

Bed-sores  are  prevented  by  scrupulous  cleanliness  as  regards 
the  patient  and  the  bed,  and  by  the  avoidance  of  uneven  pres- 
sure such  as  caused  by  crumbs,  wrinkled  sheets,  etc.  Bath- 
ing with  alcohol,  frequent  changing  of  the  patient's  position, 
and  the  use  of  an  air  cushion  are  of  value. 


PARATYPHOID    FEVER.  3 1 

Lobar  pneumonia  and  bronchial  catarrh  call  "-for  dry  cups 
and  the  use  of  the  following  mixture : 

I^.     Ammonii  chlorid oij  8.  gm. 

Strychninae  sulphat gr.  1/3  .02     gm. 

Spts.  chloroformi.  ......    f  3j  4-  C-C. 

Aq.  lauro-cerasi.  q.  s.  ad  f  5iv  120.  c.c. 

M.  S. — Dessertspoonful    every    two,  three,    or  four  hours, 
diluted. 

In  all  cases  the  patient  should  be  supported  by  the  admin- 
istration of  strychnin  sulphate,  gr.  1/32  (0.002  gm.),  every 
four  hours,  and  if  the  debility  becomes  extreme  aromatic 
spirits  of  ammonia,  f5i  (4  c.c),  or  spirits  of  chloroform,  ni^ii 
(0.12  to  0.3  c.c),  may  be  given  every  two  hours  in  addition. 
If  the  tongue  becomes  dry,  brown  and  fissured,  the  following 
formula  will  be  found  useful : 

]^.      Olei  terebinthinae f§ss  15.  c.c. 

Mucil.  acacise q.s.  q.s. 

01.  sassafras.  .  .  ., il^v  i .         c.c. 

Aq.  chloroformi  .q.  s.  ad    f  §iv  120.  c.c. 

M.  S. — One  teaspoonful  every  two  or  three  hours,  diluted. 

Convalescence  should  be  carefully  guarded.  The  return 
to  solid  food  should  be  extremely  slow.  Exercise  should  be 
of  the  most  mild  character  for  several  weeks.  Quinin  and 
belladonna,  internally,  will  serve  to  control  cardiac  palpita- 
tion and  excessive  sweating  during  this  period.  Any  ten- 
dency toward  diarrhea  may  be  checked  by  nitrate  of  silver, 
nux  vomica,  or  strychnin.  The  malt  liquors  are  of  value  in 
prolonged  convalescence.  The  elixir  of  iron,  quinin,  and 
strychnin   (N.  F.)  is  useful. 

PARATYPHOID  FEVER.     . 

This  is  an  infectious  fever  produced  by  a  special  bacillus,  in- 
termediate between  the  typhoid  and  colon  form,  called  the 
paratyphoid  bacillus,  and  possessing  clinical  features  similar 
to  those  of  typhoid,  but  of  milder  type.     Diarrhea  and  ter- 


32  TYPHUS   FEVER. 

mination  of  fever  by  crisis  are  more  common  than  in  typhoid. 
There  are  no  characeristic  lesions.  Intestinal  ulceration  is 
never  present.  Purulent  arthritis  and  myositis  may  occur 
as  complications  in  this  disease,  but  are  very  infrequent  in 
typhoid.  The  blood  serum  in  this  disease  gives  an  agglutina- 
tion reaction  with  fresh  cultures  of  the  paratyphoid  bacillus, 
but  not  with  typhoid  cultures.  The  diazo- reaction  is  generally 
positive.  The  outlook  is  more  favorable  than  in  typhoid 
fever,  and  the  treatment  is  the  same. 

TYPHUS  FEVER. 

Synonyms. — Contagious  fever;  ship  fever;  jail  fever;  pe- 
techial typhus;  spotted  or  putrid  fever;  the  Germans  call  it 
exanthematic  typhus  to  distinguish  it  from  abdominal  typhus 
(typhoid). 

Definition. — An  acute,  infectious,  febrile,  epidemic  disease; 
highly  contagious,  and  characterized  by  sudden  invasion, 
profound  depression  of  the  vital  'powers,  sickening  odor, 
and  a  peculiar  maculated  and  petechial  eruption,  favorable 
cases  terminating  by  crisis  about  the  fourteenth  day.  There 
are  no  characteristic  lesions. 

Cause. — A  special  infecting  germ,  the  character  of  which 
is  unknown,  and  which  is  influenced  by  filth  and  overcrowd- 
ing.    The  disease  is  rarely  seen  in  the  United  States. 

Pathology. — There  are  no  constant  lesions  peculiar  to  this 
affection.  The  blood  is  dark  and  thin,  with  a  decrease  in 
fibrin;  and  the  tissues  are  affected  with  parenchymatous  de- 
generations.    The  petechial  rash  remains  after  death. 

Symptoms.— After  an  incubation  period  varying  from  a 
few  hours  to  two  weeks  (generally  about  twelve  days)  the 
disease  makes  its  appearance  suddenly  with  a  chill,  followed 
by  pains  in  the  head,  back,  and  limbs,  and  fever,  the  tempera- 
ture reaching  105°  or  106°  F.  within  a  few  days.  The  high 
temperature  is  maintained  for  about  two  weeks  when  it  falls 
by  crisis.  The  pulse  is  at  first  frequent  and  bounding,  but 
soon  becomes  small,  weak  and  rapid.     Prostration  is  'extreme 


TYPHUS    FEVER 


33 


and  is  manifested  by  muscular  feebleness,  vertigo,  tremor, 
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becomes  petechial  or  hemorrhagic.  Associated  with  this  is 
diffuse  mottling  of  the  skin  which  involves  the  entire  body, 
excepting  the  face.  The  face  has  a  uniform  deep  dusky  flush 
and   the  skin   appears  glazed.      The  conjunctivae  are    injected 


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Nursing.) 

and  the  pupils  are  contracted.  As  the  disease  progresses  there 
is  cutaneous  hyperesthesia,  muscular  soreness,  and  tender- 
ness over  the  tibia.  Headache  is  severe  and  often  followed 
by  delirium.  Constipation  is  the  rule.  The  urine  is  that  of 
all  high  fevers. 

Complications. — Bronchopneumonia,  gangrene  of  the  lungs, 
and  swollen  parotid  glands  are  the  most  common;  hyper- 
pyrexia, early  typhoid  state,  and  bed-sores  are  also  to  be 
expected. 

Diagnosis. — It  may  be  distinguished  from  typhoid  fever  by 
3 


i 


34  CEREBROSPINAL   FEVER. 

the  sudden  onset,  the  rapid  rise  of  temperature,  the  fever  record, 
the  earHer  appearance  and  distribution  of  the  eruption,  and 
the  absence  of  abdominal  symptoms,  Widal  reaction,  and 
diazo-reaction. 

Measles  begins  with  coryza  and  cough  and  has  an  entirely 
different  course  except  in  the  case  of  hemorrhagic  measles; 
Koplik's  spots  are  often  found. 

Cerebrospinal  fever  is  attended  by  more  intense  nervous 
phenomena  but  there  is  no  constant  eruption.  Prostration 
is  not  so  great,  vomiting  is  more  common,  and  the  fever  is 
not  quite  so  high;  the  character  of  the  prevailing  epidemic 
will  often  help.  Lumbar  puncture  and  Kernig's  sign  will  settle 
the  diagnosis. 

Prognosis. — The  duration  is  usually  about  two  weeks  and 
the  mortality  varies  from  5  to  35  per  cent.  High  temperature, 
frequent  pulse,  early  stupor,  and  great  anxiety  are  unfavor- 
able indications. 

Treatment. — Isolation  is  imperative.  Disinfection  of  clothing 
and  excreta  is  necessary.  The  patient  should  be  treated  in 
the  open  air  if  possible  and  the  various  symptoms  combated 
as  in  typhoid  fever.  Hydrotherapy  should  be  employed  to 
reduce  the  temperature;  apart  from  this  there  is  no  special 
treatment,  except  to  support  and  stimulate  the  patient. 

CEREBROSPINAL  FEVER. 

Synonyms. — Epidemic  cerebrospinal  meningitis;  epidemic 
cerebrospinal  fever;  spotted  fever;  petechial  fever. 

Definition. — An  acute  severe  infectious  fever,  characterized 
by  headache,  vomiting,  painful  contractions  of  the  muscles 
of  the  back  of  the  neck,  retraction  of  the  head,  hyperesthesia, 
disorders  of  the  special  senses,  delirium,  stupor,  coma,  and 
frequently  an  eruption  of  petechias  or  purpuric  spots.  Lesions 
of  cerebral  and  spinal  membranes  are  found  at  the  post- 
mortem. 

Causes. — The  disease  is  believed  to  be  due  to  the  Diplococ- 
cus  intracellular  is  of  Weichselbaum  and  also  to  mixed  in- 
fection.    The    organism    is    found   in   the    fluid    obtained    by 


CEREBROSPINAL   FEVER.  35 

lumbar  puncture.  The  pneumococcus  may  also  produce  this 
disease.  Among  the  predisposing  causes  may  be  mentioned 
bad  hygiene,  filth,  overcrowding,  foul  air,  poor  food,  impure 
water,  exposure,  winter  season,  and  youth.  It  is  but  slightly 
contagious  and  the  method  of  its  transmission  is  unknown. 
It  is  epidemic  and  sporadic. 

Pathologic  Anatomy. — In  nearly  all  cases  there  is  hyper- 
emia of  the  membranes  (pia  and  arachnoid)  of  the  brain  and 
spinal  cord  followed  by  an  exudation  of 
lymph  and  an  effusion  of  serum  most  marked 
at  the  base  of  the  brain.  The  cranial  and 
spinal  nerves  are  similarly  affected  in  severe 
cases.  The  lungs,  spleen,  stomach,  liv^r, 
kidneys,  bladder,  and  muscles  are  in  various 
stages  of  congestion  and  parenchymatous 
degenerations.  In  some  cases  death  results  fig.  4.— Dipiococcus 
from  profound  toxemia  before  structural  dls^Tweichseibaum"f^in 
changes  have  taken  place.  ^^^  arl'orSI  gone! 

Symptoms. — The     common     form    begins   coccus)  chiefly  withm  the 

-'       -^  y  o  polynuclear      leucocytes. 

abruptly   with   a   chill,    excruciating    head-    {Greene's    Medical 

^  ...  Diagnosis.) 

ache,   persistent  nausea,  vomiting,   vertigo, 

and  weakness.  The  muscles  of  the  back  of  the  neck  soon 
become  rigid  and  retracted.  The  muscles  of  the  back  are 
shortly  involved  in  a  similar  manner,  resulting  in  opisthotonus, 
or  arching  of  the  back.  Kernig's  sign  (inability  to  straighten 
the  leg  completely  when  the  thigh  is  flexed  at  a  right  angle 
with  the  pelvis,  the  patient  being  in  the  recumbent  posture) 
is  nearly  always  obtained;  and  as  it  is  almost  never  found  in 
other  diseases,  or  in  health,  it  is  practically  pathognomonic 
of  this  disease.  There  is  great  restlessness  and  the  surface 
of  the  body  becomes  hyperesthetic.  Muscular  cramps  are 
common  and  convulsions  and  delirium  are  frequent.  Arth- 
ritis is  not  uncommon.  Involvement  of  the  special  nerves 
induces  intolerance  to  light  and  sound,  blindness,  deafness, 
loss  of  senses  of  smell  and  taste,  tremor  of  the  eyeballs  and 
paralysis  of  ocular  muscles.  The  temperature  and  pulse 
record     are     irregular.     Emaciation     is     usually     present.     A 


i 


36 


CEREBROSPINAL   FEVER. 


petechial  or  purpuric  eruption  makes  its  appearance  from  the 
first  to  the  fifth  day.  Herpes  faciaHs,  erythema,  or  urticaria 
may  also  be  present.  The  tache  cerehrale  is  usually  obtained. 
Leukocytosis  of  about  25,000  to  40,000  per  cm.  is  always 
present.  The  duration  of  this  form  is  from  a  few  hours  to 
several  weeks  but  usually  it  reaches  its  height  in  from  three 
to  eight  days,  passing  into  either  stupor  and  coma  or  into  a 
protracted  convalescence. 


Fig.  5. — Kernig's  sign. 
Proper  method,  i.  e.,  pre- 
liminary flexion  of  thighs 
on  abdomen  followed  by- 
attempted  extension  of  leg 
on  thigh.  {Greene's  Medical 
Diagnosis.) 


Fig.  6. — Kernig's  sign, 
Improper  method  lacking 
the  essential  preliminary- 
flexion  of  thighs  upon  ab- 
domen. (From  Greene's 
Medical  Diagnosis.  After 
Sahli-Wiener.) 


The  fulminant  or  malignant  form  is  characterized  by  sudden 
onset,  violent  chills,  depression,  and  in  a  few  hours  collapse 
and  death. 

The  abortive  form  consists  of  one  or  more  pronounced  char- 
acteristic symptoms  during  the  course  of  an  epidemic,  and 
terminates  in  prompt  recovery. 

The  chronic  form,  is  that  in  which  the  duration  is  unusuall}^ 
prolonged,  and  is  attended  by  headache,  gastric  irritability,  and 
vague  pains;  it  usually  terminates  in  death  from  exhaustion 
or  in  incomplete  recovery. 

Complications  and  Sequelae. — The  common  complications 
are  pleurisy,  pneumonia,  endocarditis,  pericarditis,  typhoid 
fever,  polyarthritis,  and  intestinal  catarrh.  As  sequels  may 
be  mentioned  persistent  headache,  blindness,  deafness,  mental 


CEREBROSPINAL   FEVER.  37 

feebleness,  chronic  hydrocephalus,  epilepsy,  and  various 
palsies. 

Diagnosis. — This  is  made  from  the  symptoms,  particularly 
Kernig's  sign.  Lumbar  puncture,  in  the  third  or  fourth  lum- 
bar interspace,  will  often  show  the  cerebrospinal  fluid  turbid, 
bloody,  or  purulent,  and  microscopic  examination  will  demon- 
strate the  microorganism. 

Differential,  Diagnosis. — Typhoid  fever  begins  slowly  and 
has  a  characteristic  temperature,  less  headache,  and  no  mus- 
cular rigidity  or  opisthotonus.  The  eruption,  diarrhea,  ab- 
sence of  palsies  and  Kernig's  sign,  and  the  presence  of  Widal's 
reaction  should  serve  to  make  the  distinction. 

Typhus  fever  has  a  definite  course  and  eruption  and  is  not 
attended  by  muscular  rigidity,  retraction,  disorders  of  the 
special  senses,  or  palsies. 

Tubercular  meningitis  differs  in  that  it  is  not  epidemic,  has 
no  eruption,  is  preceded  by  long  prodromes,  runs  a  tedious 
course,  and  a  primary  focus  of  tuberculosis  may  usually 
be  detected  elsewhere  in  the  body. 

A  careful  history  and  examination  will  serve  to  differen- 
tiate it  from  small-pox,  influenza,  and  acute  articular  rheu- 
matism,  which  it  sometimes  resembles. 

Prognosis. — The  course  of  the  disease  is  variable  and  uncertain. 
The  mortality  varies  according  to  the  epidemic  from  20  to  75  per 
cent.     Severe  cerebral  symptoms  are  of  unfavorable  significance. 

Treatment. — The  treatment  is  symptomatic  and  sup- 
portive. The  patient  should  be  isolated  in  a  large  airy  room 
which  is  quiet,  well  ventilated,  and  moderately  dark;  he 
should  be  placed  in  bed  and  nourished  by  milk,  eggs,  meat- 
juice,  broths,  etc.,  at  regular  intervals.  Nutritive  enemas 
may  be  necessary.  Morphin  sulphate,  gr.  1/4  to  1/2  (0.016 
to  0.032  gm.),  should  be  given  hypodermically  every  two 
hours  or  extract  of  opium,  gr.  i  (0.065  g"^.),  may  be  admin- 
istered by  the  mouth  every  hour  until  the  stage  of  effusion  and 
its  consequent  pressure  symptoms  appear.  Quinin  sulphate 
and  potassium  iodid  are  then  indicated.  Da  Costa  alternates 
potassium   bromid   with   opium,    especially   in   children.     The 


38  RELAPSING   FEVER. 

convulsions  may  be  relieved  by  chloral,  gr.  xxx  (2  gm.),  given 
as  the  occasion  requires  it.  The  coal-tar  products  are  dan- 
gerous in  this  disease  and  should  be  used  only  with  the  great- 
est caution.  Whiskey  and  brandy  are  indicated  to  combat 
collapse  but  should  not  be  used  in  the  early  stage.  All  secre- 
tions and  discharges,  and  everything  that  has  been  in  contact 
with  the  patient  must  be  disinfected.  * 

Locally,  cold  compresses  and  ice-bags  should  be  applied  to 
the  head  and  spine  and  counterirritation,  cupping,  and  leeching 
over  the  spine  may  be  employed.  Repeated  lumbar  punc- 
tures are  sometimes  of  value.  Injection  into  the  spinal  canal 
of  lysol  (i  per  cent,  solution)  and  diphtheria  antitoxin  have 
been  employed  with  some  degree  of  success.  Goldscheider 
advocates  active  movements  of  the  patient  while  submerged 
in  a  bath  at  ordinary  temperatures. 

Serum  treatment  is  at  present  on  trial.  "  Flexner  recommends 
doses  of  30  c.c.  of  his  serum  to  be  injected  directly  into  the  spinal 
meninges  after  the  withdrawal  of  50  c.c.  of  cerebrospinal  fluid; 
of  400  cases  thus  treated,  295  recovered"  (Osier). 

RELAPSING  FEVER. 

Synonyms. — Febris  recurrens;  famine  fever;  spirillum  fever; 
seven-day  fever. 

Definition. — An  acute,  infectious,  contagious,  epidemic, 
febrile  disease,  self-limited,  characterized  by  a  febrile  par- 
oxysm, lasting  about  six  days,  succeeded  by  an  entire  inter- 
mission of  the  same  duration,  which  is  in  turn  followed  by  a 
relapse  similar  to  the  first  seizure. 

Cause. — The  disease  is  due  to  the  Spirochoeta  Ohermeieri, 
a  cork-screw-shaped  microorganism.  The  predisposing  factors 
in  the  production  of  this  disease  are  overcrowding,  bad  hy- 
giene, filth,  poor  food,  impure  air,  and  destitution;  the  bed- 
bug is  believed  to  be  a  common  means  of  spreading  the  disease. 

Pathologic  Anatomy. — There  are  no  structural  changes 
distinctive  of  this  disease.  The  spleen  is  enlarged  and  usually 
covered  with  a  fresh  fibrinous  exudation ;  and  the  splenic  pulp 
is  softened  and  shows  enlarged  Malpighian  bodies.     The  liver 


RELAPSING   FEVER. 


39 


and  kidneys  are  swollen  and  congested.  There  may  be  catarrhal 
inflammation  of  the  stomach  and  bile-ducts.  The  microorgan- 
isms are  found  in  the  blood  only  during  the  febrile  paroxysms 
in  the  living  subject. 

Symptoms. — The  onset  is  sudden  with  a  chill  followed  by 
fever,  102°  to  104°  F.,  frequent,  rather  weak  pulse,  headache, 
nausea,   vomiting,   and  lancinating  pains  most  marked  in  the 


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-Clinical    chart    of    relapsing  fever  showing  the  febrile  movement  upon  the 
fourteenth  day.      {From  Wilcox  s  Fever  Nursing.) 


back  and  the  calves  of  the  legs.  On  the  second  day  there  is 
a  sense  of  fullness  in  the  upper  part  of  the  abdomen  due  to 
swelling  of  the  liver  and  spleen.  Jaundice  and  sweats  are 
common.  The  fever  falls  by  crisis  on  the  seventh  day  to  re- 
appear on  the  fourteenth  day,  but  with  less  severity.  The 
symptoms  then  continue  for  about  four  days  wlien  convales- 
cence slowly  begins.     There  may  be  more  than  one  relapse. 

Complications. — Bronchitis,  pneumonia,  albuminuria,  hem- 
aturia, paralysis,  and  ophthalmia  are  the  more  frequent  com- 
plications. 


40  MALTA   FEVER. 

Diagnosis. — The  history,  temperature  record,  .and  the 
presence  of  the  microorganisms  in  the  blood  (during  the 
fever  only),  will  serve  to  distinguish  this 
affection  from  yellow  fever,  remittent  fever, 
or  any  other  disease  with  which  it  may  be 
confounded. 

Prognosis. — Recovery   is   the  rule  in  un- 
complicated cases. 

Treatment. — Immediate  isolation  and  dis- 
FiG    8  —Spirillum   of  infection  are  necessary  to  prevent  the  spread 
'c±i&(fJ^iU'''¥S;  oi  the  disease.     Rest  in  bed,  nutritious  and 
organism  is  usually  longer  easily  digested  food,  and  careful  nursing  are 

than  ishereshown.  -^         °  '  ° 

(From  Greene's  Medical  essential.      The   symptoms   are  treated,  as 

Dtagnosts.)  .  ,         .       .    , 

they  arise,  on  general  principles,  there  being 
no  special  treatment.  At  the  crisis  stimulants  and  tonics  may 
be  required,  specially  by  enfeebled  persons. 

MALTA  FEVER. 

Synonyms. — Mediterranean  fever;  undulant  fever;  Nea- 
politan fever;  rock  fever;  Gibraltar  fever. 

Definition. — An  endemic  infectious  disease,  characterized 
by  an  irregular  fever,  profuse  sweats,  pain,  arthritis,  enlarged 
spleen,  and  a  tendency  to  relapse. 

Etiology. — It  is  due  to  the  micrococcus  melitensis  of  Bruce.  The 
infection  is  supposed  to  be  carried  by  goats'  milk ;  formerly  the  air, 
water  and  mosquitos  were  put  forward  as  the  carriers  of  the  dis- 
ease.   It  chiefly  attacks  the  young  (between  six  and  thirty  years) . 

Pathology. — The  liver  is  enlarged  and  congested,  the  spleen 
is  enlarged,  hyperemic  and  soft ;  in  both  of  these  organs  the 
micrococcus  is  found  in  large  numbers.  The  lungs  and  intes- 
tines may  also  be  congested. 

Symptoms. — The  period  of  incubation  is  from  six  to  ten 
days.  The  onset  is  slow,  with  headache,  restlessness,  pros- 
tration, and  gradual  rise  of  temperature  for  three  or  four 
days.  There  may  be  epistaxis  and  coated  tongue;  constipa- 
tion is  generally  present,  and  the  spleen  is  enlarged.  A  pro- 
fuse   sweat    occurs    at    night,    and   there    are    sudamina,    but 


MALARIA.  41 

no  rose.-spots  or  tympanites.  As  the  temperature  falls  to  nor- 
mal the  other  symptoms  abate  and  the  patient  feels  convales- 
cent, but  a  relapse  occurs,  and  the  symptoms  return,  often 
with  increased  severity.  After  another  three  or  four  weeks 
there  is  another  interval,  followed  by  another  relapse;  and  so 
the  disease  goes  on  and  may  be  prolonged  for  months. 

Complications  and  Sequelae. — Pneumonia,  neuralgia,  or- 
chitis and  anemia. 

Prognosis  is  good;  the  death  rate  is  about  2  or  3  per  cent. 
Treatment. — This     is     symptomatic     and     supportive     and 
somewhat  on  the  lines  of  that  for  typhoid. 

MALARIA. 

Synonyms. — Ague;  fever  and  ague;  chills  and  fever;  marsh 
fever;  swamp  fever;  see  also  below,  under  remittent  fever 
(page  48),  and  pernicious  malarial  fever  (page  49). 

It  would  be  well  to  abolish  all  of  these,  also  the  now  mean- 
ingless name  malaria,  and  to  substitute  the  term  mosquito 
fever  or  anopheles  fever. 

Definition. — An  infectious  fever,  intermittent  or  remittent 
(see  page  7)  in  type,  characterized  by  enlargement  of  the 
spleen,  chills,  and  anemia  and  due  to  the  H^mamoeba,  Plasmo- 
dium malaricE  of  Laveran.  {Note. — This  is  a  protozoon,  not  a 
bacterium.) 

Cause.— The  exciting  cause  is  the  microorganism,  already 
mentioned,  which  gains  access  to  the  body  through  the  bites 
of  mosquitos  belonging  to  the  genus  anopheles.  The  predis- 
.  posing  causes  are  those  factors  that  favor  mosquito  life,  namely, 
marshy  districts,  high  temperatures,  humidity,  and  absence 
of  winds.  On  account  of  the  nocturnal  habits  of  the  anopheles 
the  disease  is  more  Mkely  to  be  contracted  at  night.  It  should 
be  noted  that  mosquitos  do  not  cause  malaria  but  they 
carry  it  from  those  who  have  it  to  those  who  do  not  have  it. 

There  are  three  varieties  of  mosquitos  which  are  of  medi- 
cal interest  and  the  following  table  (from  Jackson's  Tropical 
Medicine)  will  be  found  helpful  to  the  practitioner  and  the 
student. 


42 


MALARIA. 


Stegomyia. 


Anopheles. 


Diseases 
conveyed. 

Mostly      nonpatho-     Stegomyia        fasciata 
genie     for    man    but       conveys        yellow 
may    convey    filarial      fever  in  man. 
diseases. 

Conveys  malarial  dis- 
ease. Conveys  fil- 
arial disease  in  man. 

Breeds 

In  and  about  houses.    Resembles  Culex  .  .  .  . 
gardens,  back  yards, 
old    flower    pots,    or 
tins,     vessels,     tubs, 
cisterns,  barrels,  gut- 
ters, drains. 

"  Home  bred." 

Puddle  breeding — 
shallow,  small  pools, 
in  rock  or  soil,  also 
at  margins  of  lakes 
and  rivers,  quiet 
bays,  ponds,  in  rice 
fields  and  water 
covering  submerged 
grass. 

Less  "home  bred." 

Bites By  day  or  night — at    Often    bites    by    day. 

twilight.         Females      Females  only. 
I      only. 

Nocturnal  chiefly. 
Females  only. 

Wings !    Rarely  spotted Never  spotted 

Usually  spotted. 
There  are  a  few  ex- 
ceptions. 

Larval  motility.]   Larvae      float      withj    Resemble  Cu lex 

'      heads      downward. 
When     disturbed 
wriggle  to  bottom  ofi 
vessel. 

■ 

Float  at  surface  of 
water  like  sticks  and 
have  a  backward, 
skating  motion. 

Resting  posture.     "Hunch-backed." 
Axis    of    head    and 
proboscis    forms    an 
obtuse     angle     with 
body. 

Resembles  Culex,  .  .  . 

Axis  of  head,  probos- 
cis and  body  in  same 
line.  Appears  as  if 
standing  on  its  head. 
Some  exceptions  to 
this  rule. 

Eggs 

Deposited    in    ellipse- 
shaped   masses,  con- 
vex below,   concave 
above     (boat     shap- 
ed).    Eggs  arranged 
in    rows,    perpendic- 
ular   and    adherent, 
have      one      pointed 
end.         Color     dirty 
white.    200  to  400  in 
a  batch. 

Eggs    are    more    oval 
and    are   not    depos- 
ited     in      rafts      or 
masses.    Float  singly 
upon  their  sides,   or 
sink,    hatching    sub- 
merged . 

Deposited  in  masses 
of  40  to  100  eggs, 
not  adherent,  each 
egg  floating  on  its 
side,  and  regularly 
elliptic  in  outline,  at 
middle  of  each  side 
appears  a  clasping 
wrinkled  membrane. 
Dark  in  color. 

Singing   tone.  .  .  1   High  pitched 

Resembles  Culex  .... 

Low  pitched 

Bodies 

1 

i 

Dull  gray  in  color. .  .  . 

Body  and  legs  cover- 
ed with  black  scales 
and  white  markings 
in     spots     or     lines. 

S.  Fasciata  has  trans- 
verse    striations    on 
ventral      aspect      of 
body. 

Dark  gray  or  brown. 

MALARIA.  43 

Three  forms  of  the  microorganism  have  been  recognized. 
The  first  or  tertian  parasite  is  characterized  in  the  early  period 
by  small  hyaline  bodies  possessed  of  ameboid  movements. 
At  first  they  occupy  but  a  few  of  the  red  blood  cells  but  as 
they  increase  in  size  and  number  they  become  surrounded  by 
pigment  granules.  As  the  organism  enlarges  the  pigment 
collects  toward  the  center  and  the  ameboid  movements  cease. 
Segmentation  then  begins  and  the  parasite  divides  into  from 
15  to  25  parts  or  spores.  The  already  distended  blood  cell 
now  ruptures  discharging  the  spores  into  the  blood  stream. 
This  cycle  is  repe&ted.  The  chills  occur  simultaneously 
with  the  discharge  of  the  spores.  For  the  completion  of  this 
cycle  forty-eight  hours  are  usually  required,  so  that  a  single 
group  of  these  parasites  induces  a  paroxysm  every  other  day 
{tertian  fever).  The  presence  of  two  distinct  groups  sporulat- 
ing  on  alternate  days  gives  rise  to  a  daily  paroxysm  {quotidian 
fever) . 

The  second  form  or  quartan  parasite  has  less  pigment,  of  a 
more  coarse  quality,  less  spores,  and  its  segmentation  requires 
seventy -two  hours.  One  group  will  cause  a  paroxysm  every 
third  day  (with  an  intermission  of  two  days)  {quartan  fever) ; 
two  groups  sporulating  on  two  successive  days,  the  paroxysms 
will  occur  on  two  successive  days  being  separated  by  an  inter- 
val of  one  day  {double  quartan  fever).  In  the  presence  of  three 
such    groups,    daily    paroxysms    will    occur    {quotidian  fever). 

The  third  or  estivo-autumnal  parasite  is  smaller,  being  about 
one-half  the  size  of  a  red  blood  cell,  and  contains  less  pigment 
than  the  preceding.  Within  the  blood  cells  it  appears  as  a 
group  of  small  hyaline  bodies  and  soon  causes  the  corpuscles 
containing  it  to  assume  a  shrunken,  crenated,  and  brassy  ap- 
pearance. After  a  week  or  more  large  ovoid  bodies,  cres- 
centic  in  shape,  appear  in  the  corpuscles.  Segmentation 
occurs  only  in  the  spleen  and  other  internal  organs.  The 
entire  cycle  of  this  parasite  covers  forty-eight  hours. 

Flagellated  forms  are  sometimes  observed  and  are  be- 
lieved to  be  concerned  in  the  reproductions  of  these  organisms. 

In   the   United  States  the   tertian  is  the  common  form,  the 


44 


MALARIA. 


quartan   being  rare;   these  two   are  rarely  fatal  and    respond 
readily  to  quinin.     The  esHvo-autumnal  is  found  in  the  tropics, 

SINGLE  TERTIAN  INFECTION. 
Paroxysm  every  third  day. 

P.  P.  P.  P.  P.  P.  P. 

******* 

/ V  V — V V v V 

Day.     12         3  4         5  6         7  S        9  10       11         12       13 


DOUBLE  TERTIAN  INFECTION. 
Daily  paroxysm. 
P.        P.        P.        P.        P.        P.        P.        P. 


Day.    1         '2  3         4  5  6         7  8         9         10        11        12 


SINGLE  QUARTAN  INFECTION. 

Paroxysm  every  fourth  day. 

P.  P.  P  P.  P. 

Sr  *  *  *  * 

/ V y/ V V 

Day.    12  3  4         5  6  7  8  9         10        11        12        13 


DOUBLE  QUARTAN  INFECTION. 

Paroxysm  on  two  successive  days  with  oae  day's  intermission. 

P.        P.  P.        P.  P.        P.  P.         P.  P. 


Day.    1  2  3         4  5  6         7  8  9         10         11         12       13         14 


TRIPLE  QUARTAN  INFECTION. 
Daily  paroxysm. 
P.        P.        P.        P.         P.        P.       P.        P. 


Day.    1 

CHART  ILLUSTRATING  THE  DIFFERENT  TYPES  OF  FEVER 
RESULTING  FROM  INFECTION  WITH  SINGLE  AND  WITH 
MULTIPLE   GROUPS  OF   MALARIAL   PARASITES. 

The  duration  of  the  parasites'  cycle  of  development 
is  expressed  by  colored  lines,  thus: 
Black:    First    group   of  parasites. 
Red:      Second.  "        "        •*    " 
Blue:     Third        "         '♦       "    " 
P:  Paroxysm. 

Fig.  9. — (From  Da  Costa's  Clinical  Hematology.) 

is  more  fatal,  has  a  more  irregiilar  course,  and  does  not  re- 
spond so  readily  to  quinin.  \ 


INTERMITTENT   FEVER.  45 

Strictly  speaking,  the  term  Plasmodium  malaricB  belongs 
only  to  the  parasite  of  quartan  fever;  the  parasite  of  tertian 
fever  being  the  Plasmodium  vivax;  and  that  of  estivo-autum- 
nal  fever  being  the  Plasmodium  prcEcox.  But  the  term 
Plasmodium  malaricB  is  often,  loosely,  applied  to  all  varieties. 

Pathologic  Anatomy. — Disintegration  of  the  blood  cells 
is  the  most  marked  feature  of  the  acute  forms,  while  in  the 
chronic  forms  permanent  enlargement  of  the  spleen  from 
overgrowth  of  fibrous  tissue  is  a  common  result. 

Varieties. — The  principal  forms  of  malaria  are  intermittent 
fever,  remittent  fever,  and  pernicious  malaria. 

Diagnosis. — This  is  made  absolutely  by  the  presence  of  the 
Plasmodium;  other  diagnostic  points  are  the  presence  of  pig- 
mented leukocytes,  a  mononuclear  leukocytosis,  an  enlarged 
spleen,  and  response  to  quinin 

INTERMITTENT  FEVER. 

Intermittent  fever  is  a  variety  of  malaria,  characterized 
by  a  cold,  a  hot,  and  a  sweating  stage,  followed  by  an  interval 
of  complete  intermission  or  apyrexia,  varying  in  length  ac- 
cording to  the  character  and  group  of  the  malarial  organism. 

Symptoms. — The  cold  stage  begins  with  lassitude,  yawning, 
headache,  and  nausea,  followed  by  a  severe  chill  in  which  the 
teeth  chatter,  the  skin  becomes  pale,  cold,  and  rough  {ciitis 
anserina),  the  nails  and  lips  are  blue,  and  the  features  are 
pinched.  There  is  great  thirst  and  the  thermometer  shows 
a  rise  of  temperature  to  102°  to  104°  F.  These  phenomena 
last  from  one-half  hour  to  an  hour. 

The  hot  stage  begins  as  the  shivering  ceases  and  the  temper- 
ature rises  still  higher,  106°  F.  or  more.  The  body-surface 
becomes  hot  and  flushed  and  the  pulse  becomes  rapid  and  full. 
Headache,  backache,  nausea,  and  intense  thirst  are  also  pres- 
ent. The  urine  is  scanty,  high-colored,  and  of  increased 
specific  gravity.     This  stage  lasts  from  one  to  ten  hours. 

The  sweating  stage  begins  gradually,  appearing  first  on  the 
forehead  and  gradually  extending  over  the  entire  surface 
of  the  body.     All  the  symptoms  subside  as  the  perspiration 


46 


INTERMITTENT    FEVER. 


becomes  free.  This  period  lasts  from  one  to  four  hours  and 
is  often  followed  by  a  refreshing  sleep. 

An  intermission,  of  varying  length,  then  occurs  after  which 
another  attack  begins,  being  ushered  in  with  chilliness  or  pain. 

Intermittent  fever  is  attended  by  enlargement  of  the  spleen, 
anemia,   and  pigmentation  of  the  leukocytes  but  no  increase 


A-H.Ebelinff  7.o» , 


Fig.  io. — Metamorphosis  of  mosquitos.  i,  2,  3,  4  and  5,  Eggs,  larva,  pupa  and 
heads  of  male  and  female  Culex;  6,  7,  8,  9  and  10,  eggs,  larva,  pupa  a  id  heads  of  male 
and  female  Anopheles;  11,  12,  13,  14  and  15,  eggs,  larva,  pupa  and  heads  of  male  and 
female  Stegomyia.      (From  Stitt's  Practical  Bacteriology.) 

in  their  number.  It  may  be  mistaken  in  a  hasty  examination 
for  hectic  fever,  pyemia,  or  nervous  chills  but  the  finding  of 
the  organism  in  the  blood  will  correct  any  error  in  diagnosis. 
Prognosis. — Recovery  is  the  rule  with  treatment.  Neg- 
lected cases  may  terminate  favorably  after  several  paroxysms 
but  are  more  likely  to  pass  over  into  chronic  malaria  or  mala- 
rial cachexia. 


INTERMITTENT   FEVER. 


47 


Treatment. — The  cold  stage  may  be,  to  a  large  extent, 
averted  by  the  hypodermic  injection  of  morphin  sulphate, 
gr.  i/8to  1/4  (0.008  to  0.016  gra.),  or  pilocarpin  hydrochlorid, 
gr.  1/8  (0.008  gm.),  or  by  the  internal  administration  of  spirits 
of  chloroform,  f3j  (4  c.c).  During  the  hot  stage  cool  drinks 
and  cool  sponging  are  indicated,  and  during  the  sweating 
stage  the  patient  should  be  sponged  with  alum  and  hot  water. 


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Fig.  II. — Clinical  chart  of  ordinary  or  tertian  malaria  showing  three  febrile  paroxysms 
occurring  on  alternate  days.      {From.  Wilcox  s  Fever  Nursing.) 


In  the  intermission  the  bowels  should  be  opened  by  the 
administration  of  5  gr.  (0.32  gm.)  each  of  calomel  and  sodium 
bicarbonate  followed  by  an  active  saline  cathartic. 

Quinin  is  a  specific  for  this  disease.  Quinin  sulphate,  gr. 
X  to  XX  (.65  to  1.30  gm.),  should  be  given  in  solution  or  capsules 
in  one  or  two  doses,  three  to  five  hours  before  the  expected 
paroxysm.      Other  preparations  of  cinchona  may  also  be  used. 

After  the  paroxysms  have  been  broken  up  the  solution  of 
potassium  arsenite  (Fowler's  solution),  v(\y  to  x  (0.3  to  0.6  c.c), 


48  REMITTENT   EEVER. 

or  the  tincture  of  the  chlorid  of  iron,    rr^xx    (1.3  c.c.)  should 
be  given  every  four  hours  over  an  extended  period. 

I^.     Ferri  reducti, 

Quininse  sulphat aa  gr:  Ix  4 .  gm. 

Acidi  arsenosi gr.  j  .065  gm. 

01.  pip.  nigr tt^xv  i  .  c.c. 

M.  Ft.  pil.  No.  XXX. 

S. — One    pill    after    meals,     continued    for    one    month    or 
longer. 

Relapses  being  common,  it  is  well  to  administer  quinin  on 
the  second  or  third  day,  fourth  to  the  sixth,  twelfth  to  the 
fourteenth,  and  nineteenth  to  the  twenty-first  days  after  the 
last  paroxysm. 

Preventive  Measures. — The  prevention  of  the  disease  has 
largely  to  do  with  exterminating  mosquitos  and  avoiding 
infection  of  them  and  by  them.  The  draining  of  stagnant  pools 
and  swamps  with  their  subsequent  filling  up  is  well  recognized 
as  an  effective  measure.  The  use  of  crude  petroleum  over 
such  surfaces  has  been  found  to  destroy  the  larvas  of  the 
anopheles  in  from  two  to  four  weeks  and  where  practicable 
it  should  be  employed.  The  screening  of  the  patient  and 
other  individuals  in  malarial  districts,  during  the  sleeping  hours, 
by  means  of  ordinary  netting  is  extremely  efficacious.  Sleep- 
ing on  low  ground,  unprotected,  should  be  avoided.  Daily 
doses  of  from  5  to  10  gr.  of  quinin  sulphate  is  an  additional 
protection. 

REMITTENT  FEVER. 

Synonyms. — Bilious  fever;  bilious  remittent  fever;  marsh 
fever;  typho-malarial  fever;  estivo-autumnal  fever. 

Definition. — A  paroxysmal  fever,  with  exacerbations  and 
remissions,  in  which  the  temperature  is  constantly  above 
the  normal;  characterized  by  a  moderate  cold  stage  (which 
does  not  recur  with  each  paroxysm) ;  an  intense  hot  stage, 
with  violent  headache  and  gastric  irritability;  and  an  almost 
imperceptible    sweating    stage,    which    is    frequently   wanting. 


PERNICIOUS   MALARIAL   FEVER.  49 

This  variety  of  malaria  lasts,  as  a  rule,  from  seven  to  fourteen 
days,  and  usually  occurs  during  the  late  summer  and  early 
autumn.  Frequently  the  fever  fails  to  remit  and  becomes 
continuous  in  type. 

The  characteristics  that  serve  to  distinguish  this  affection 
are  the  temperature  record  and  the  presence  of  the  estivo- 
autumnal  parasite  already  described.  The  spleen  is  always 
enlarged  and  there  may  be  jaundice  and  delirium. 

Prognosis. — Uncomplicated  cases  usually  recover,  but  the 
disease  may  pass  over  into  malarial  cachexia  or  be  followed 
by  persistent  headache  and  vertigo. 

Treatment. — Quinin  sulphate,  gr.  xvi  (i  gm.)  per  diem, 
should  be  administered  by  the  mouth  or  rectum;  or  the  bi- 
sulphate  of  quinin  may  be  given  hypodermically  during  the 
remission.  The  following  should  also  be  given  during  this 
period : 

I^.     Hydrargyri  chlor.  mitis.    gr.  v  .3       gm. 

Sodii  bicarb gr-  v  .3       gm. 

Pulv.  ipecac gr.  ss  .03     gm. 

M.  S. — To  be  taken  as  required  according  to  the  condition 
of  the  intestinal  tract. 

During  the  hot  stage  the  patient  should  be  sponged  and  an 
ice-bag  placed  on  the  head.  If  there  is  a  tendency  to  cerebral 
congestion  dry  or  wet  cups  should  be  applied  to  the  nape  of 
the  neck  and  the  following  mixture  given: 

I^.      Tinct.  aconit ttlv  .  3  c.c. 

Liq.  ammon.  acetat f  5ij  8 .  c.c. 

Liq.  potassii  citrat f  oij  8 .  c.c. 

M.  S. — Every  two  hotirs. 

The  treatment  advised  in  intermittent  fever  is  also  applic- 
able to  this  variety  of  malaria. 

PERNICIOUS  MALARIAL  FEVER. 

Synonyms. — Congestive  fever;  malignant  intermittent  fever; 
malignant  remittent  fever;  the  congestive  chill. 

Definition. — A   malignant   malarial  fever,  which  may  be  of 

4 


50  PERNICIOUS    MALARIAL    FEVER. 

the  intermittent  or  remittent  type;  characterized  by  intense 
congestion  of  one  or  more  internal  organs,  together  with  danger- 
ous perversion  of  the  functions  of  innervation. 

It  occurs  almost  exclusively  in  warm  climates  and  is  due  to 
the  estivo-autumnal  parasite.  As  a  rule  the  pernicious  char- 
acter of  the  disease  does  not  become  manifest  until  after  the 
second  or  third  paroxysm. 

Symptoms. — The  disease  begins  as  intermittent  or  remittent 
fever,  but  with  the  migration  of  the  parasites  new  groups  of 
symptoms  arise  according  to  the  localization  of  the  organisms. 

The  gastroenteric  type  is  characterized  by  intense  nausea, 
vomiting,  purging  of  thin  discharge  mixed  with  blood,  tenes- 
mus, burning  sensations  in  the  stomach,  intense  thirst,  frequent 
weak  pulse,  cold  hands,  feet  and  face,  shrunken  features, 
cramps,  and  marked  depression.  It  lasts  from  one-half  to 
several  hours. 

The  thoracic  type  is  usually  combined  with  the  preceding 
and  is  attended  by  marked  dyspnea,  oppressed  cough  with 
blood-streaked  sputa,  frequent  weak  pulse,  cold  surface,  and 
terror-stricken  features,  all  of  which  arise  from  the  intense 
pulmonary  congestion. 

The  cerebral  type  is  marked  by  violent  delirium,  followed 
by  stupor  and  coma,  slow  full  pulse,  and  a  flushed  or  livid 
surface  due  to  congestion  of  the  brain. 

The  hemorrhagic  type  is  caused  by  distintegration  of  the 
blood  and  is  characterized  by  hemorrhages  from  the  mucous 
membranes  and  into  the  subcutaneous  tissues,  bloody  urine 
and    jaundice. 

The  algid  type  is  that  in  which  the  body-surface  is  intensely 
cold,  the  rectal  temperature  ranging  from  104°  to  107°  F.,  a 
cold  sweat  covers  the  body,  the  pulse  is  slow,  feeble,  and  often 
absent  at  the  wrist,  there  is  intense  thirst,  the  mind  is  clear, 
and  the  countenance  is  death-like. 

These  various  types  exist  visually  more   or  less   combined. 

Diagnosis. — The  predominance  of  certain  .  of  these  groups 
of  symptoms  may  cause  the  disease  to  be  mistaken  for  cerebral 
apoplexy,  meningitis,  uremia,  yellow  fever,  or  cholera,  but  a 


PERNICIOUS    MALARIAL    FEVER.  5 1 

careful  examination  of  the  blood  will  reveal  the  characteristic 
parasite  which  is  pathognomonic  of  malaria. 

Prognosis. — The  disease  continues  from  a  few  hours  to  one, 
two,  or  three  days  and  unless  controlled  prior  to  the  second 
paroxysm  is  unfavorable.  The  intermittent  forms  are  most 
favorable.     The  mortality  is  about  13  per  cent. 

Treatment.— The  patient  should  be  cinchonized  immediately 
by  the  hypodermic  injection  of  40  gr.  (2.6  gm.)  of  the  bisul- 
phate  or  bihydrochlorid  of  quinin. 

The  muriate  of  quinin  and  urea  in  10,  15  or  20  gr.  (0.66,  i, 
and  1.33  gm.)  doses  is  also  highly  recommended  for  hypodermic 
use;  and  so  is  the  following: 

I^.      Quininse  hydrochloridi  acidi  (B.  P.)    gr.  xx     1.2       gm. 

Aqusb  distillatae nxxv         i  .  00     c.c. 

M.  This  fills  an  ordinary    hypodermic    syringe  and  is  a  full 
dose. 
Intramuscular  injection  is  said  to  be  less  painful  than  sub- 
cutaneous injection. 

Methylene  blue,  in  dose  of  3  gr.  (o.i  gm.)  every  three  hours, 
in  pill  or  capsule,  has  also  been  used.  Care  must  be  taken 
to  secure  a  pure  drug. 

"Warburg's  tincture,"*  has  considerable  reputation  in  the 
various  forms  of  malarial  fevers.  It  can  be  given  in  doses 
of  half  an  ounce  and  repeated  in  three  hours;  it  is  a  powerful 
sudorific  and  can  be  prescribed  either  "with  ^oes"  or  "with- 
out aloes." 

In   the  cold  stage,  heat  and  stimulating  lotions  should  be 
applied  to  the  body-surface;  while  in  the  hot  stage,  cold  should 
be  employed  and  morphin  administered  hypodermically. 
In  the  gastroenteric  type  Da  Costa  recommends: 

Py.      Morph.  sulphat gr.  1/4  .016  gm. 

Pulv.  camph gr.  j  .065  gm. 

Mass.  hydrarg gr.  ij  .12     gm. 

Pulv.  capsici gr.  ss  .03     gm. 

M.    S. — Every  half  hour   until  the  character   of  the  stool 
is  changed. 

*For  the  original   (or  supposed  original)   formula   of  this  preparation,  see  former 
editions  of  this  woik.      It  has  only  an  historic  interest. 


52  BLACKWATER   FEVER. 

For  the  thoracic  type,  dry  or  wet  cups,  carbonate  of  am- 
monium, caffein,  and  strychnin  are  indicated,  while  for  the 
cerebral  type  venesection,  cups  or  leeches  to  the  neck,  cold  to 
the  head,  and  prompt  purgation,  diuresis,  and  diaphoresis  are 
required.  For  the  algid  type,  morphin  and  atropin,  hypoderm- 
ically,  ammonium  carbonate  and  alcoholic  stimulation  are 
necessary;  but  in  the  hemorrhagic  variety,  morphin,  turpentine, 
dilute  sulphuric  acid,  gallic  acid,  Monsel's  solution,  and  the  fol- 
lowing are  indicated: 

I^.     Fluidextracti  ergotse .  .  .  .  fBss  15.  c.c. 

Acid,  sulph.  dil f  5iss  6 .  c.c. 

Acid,  gallic 3j  4.  gm. 

Syr.  zingib f  5iij  1 2  .  c.c. 

Aquae q.  s.  ad  f  5iij   ad         90 .  c.c. 

M.  S. — Dessertspoonful  every  four  hours,  well  diluted. 

Malarial  cachexia  may  result  as  a  sequel  to  any  of  the  forms 
of  malaria  just  described.  The  patient  is  more  or  less  jaun- 
diced, the  circulation  is  poor,  the  temperature  is  usually  sub- 
normal, but  there  may  be  periodical  attacks  of  fever,  the 
spleen  is  enlarged,  and  weakness  and  emaciation  are  marked. 
Neuralgia,  headache,  hematuria,  paraplegia,  and  orchitis 
may  manifest  themselves. 

In  the  treatment  of  this  condition  iron,  quinin,  strychnin, 
arsenic,  and  cod-liver  oil  should  be  administered  over  an 
extended    period.     Occasional    cinchonism    is    also    necessary. 

BLACKWATER  FEVER. 

Synonyms. — Hemoglobinuric  fever;  malarial  hemoglobin- 
uria, or  hematuria. 

Definition. — A  tropical  disease  of  unknown  origin,  char- 
acterized by  a  hemolysis,  generally  of  short  duration,  and 
tending  to  recovery  unless  complications  (such  as  suppression 
of  urine)    occur. 

Etiology. — This  is  unknown;  there  are  three  theories:  (i) 
That  it  is  malarial;  (2)  that  it  is  due  to  quinin  poisoning;  and 
(3)  that  it  has  a  specific  origin  not  yet  determined. 


YELLOW  FEVER.  53 

Symptoms. — The  onset  is  usually  abrupt,  with  occasionally 
fever  and  malaise  as  prodromata ;  it  begins  with  a  rigor,  rapid 
rise  of  temperature,  headache,  backache,  and  vomiting.  Mic- 
turition is  apt  to  be  painful.  For  a  few  days  the  temper- 
ature is  intermittent  but  tends  to  rise,  the  maximum  being 
reached  about  the  third  day,  when  the  hemoglobinuria  appears. 
This  is  followed  by  jaundice  and  accompanied  by  thirst, 
vomiting,  polyuria,  frequent  micturition;  later  there  may  be 
retention  or  even  suppression  of  urine.  The  latter  event  is 
fatal.     Anemia  is  present  and  may  be  extreme. 

Diagnosis. — This  is  made  from  the  urine,  which  is  practi- 
cally black,  and  contains  hemoglobin;  this  latter  should  be 
sought  with  the  aid  of  the  spectroscope.  The  vomiting  and 
icterus  are  important  diagnostic  symptoms. 

Treatment. — Water  should  be  freely  administered;  quinin 
is  useless,  unless  the  malarial  parasite  is  found  in  the  blood. 
Begin  with  a  purge;  give  ice  to  suck;  apply  counterirritants 
to  the  epigastrium;  sustain  the  strength  by  nutrient  enemata 
and  alcohol.  It  must  be  remembered  that  the  disease  is  not 
hemorrhagic   in  character,  but  hemolytic. 

YELLOW  FEVER. 

Synonyms. — Yellow  Jack;  bilious  malignant  fever;  typhus 
icteroides;    Mediterranean   fever;    sailor's   fever;   black   vomit. 

Definition. — An  acute,  infectious,  paroxysmal  disease,  of 
three  stages  —  the  febrile,  the  remission,  and  the  collapse; 
characterized  by  violent  fever,  yellowness  of  the  surface,  albu- 
minuria, and  marked  tendency  to  hemorrhage  especially  in  the 
stomach,  causing  the  "black  or  coffee-ground  vomit." 

Cause. — The  disease  is  in  all  probability  caused  by  a  specific 
germ  which  has  not  yet  been  determined.  But  the  inter- 
m.ediate  host  is  a  mosquito — Stegomyia  fasciata — and  it  is  by 
means  of  this  mosquito  that  the  disease  is  transmitted.  There 
is  no  longer  any  ground  for  the  belief  in  the  transmission  of 
yellow  fever  by  fomites.  For  description  of  and  differ- 
entiation of  the  stegomyia   from  other  mosquitos,  see  above, 


54 


YELLOW   FEVER. 


page  42,  No  race,  age,  or  sex  is  exempt  from  the  disease. 
One  attack  confers  immunity,  as  a  rule.  It  is  essentially  a 
tropical  disease  and  is  most  common  during  June,  July,  August, 
and    September.      The    natives    of    warm    countries,  especially 


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Fig.  12. — Clinical  chart  of  a  yellow-fever  patient  showing  the  pulse  typically  slow  in 
comparison  to  the  height  of  the  temperature.      {From.  Wilcox's  Fever  Nursing.) 


the  negroes,   enjoy  comparative  immunity  to  the  disease  but 
strangers  are  particularly  susceptible. 

Guiteras   mentions   three   areas   of   infection:      i.    The   focal 
zone,  in  which,  up  to  1901,  the  disease  was  never  absent,  in- 


YELLOW  ||:VER.  55 

eluding  Havana,  Vera  Cruz,  Rio,  and  other  Spanish-American 
ports.  2.  Peri-focal  zone  or  regions  of  periodic  epidemics,  in- 
cluding the  ports  of  the  tropical  Alantic  in  America  and  Africa. 
3.  The  zone  of  accidental  epidemics,  between  the  parallels  of 
45°  north  and  35°  south  latitude. 

Pathologic  Anatomy. — Dissolution  of  the  red  blood  cells 
and  granular  degeneration  of  the  viscera  are  the  most  promi- 
nent structural  changes.  Jaundice,  hemorrhages,  and  fatty 
degeneration  follow  these  changes.  A  diagnosis  cannot  be 
made  from  the  post-mortem  lesions  as  none  of  them  are  dis- 
tinctive. 

Symptoms.— An  incubation  period  of  from  twenty-four 
hours  to  six  days  precedes  the  attack. 

The  first  stage  or  febrile  stage  is  ushered  in  with  malaise, 
headache,  anorexia,  or  chill,  followed  by  high  fever,  reaching 
shortly  104°  to  106°  F.,  with  pains  in  the  head,  limbs  and 
back.  The  attack  usually  begins  at  night.  The  pulse  is 
rapid,  the  face  is  flushed,  the  eyes  are  bright,  and  the  stomach 
is  irritable,  As  the  temperature  rises  the  pulse  is  at  first 
more  rapid  but  later  shows  a  marked  tendency  to  fall,  a  fea- 
ture peculiarly  characteristic.  The  patients  are  restless  and 
anxious,  and  extremely  prostrated.  The  urine  is  scanty, 
high-colored,  acid,  and  contains  albumin.  Constipation  is 
present.  A  peculiar  and  characteristic  odor  is  emitted  from 
the  patient.  The  first  stage  lasts  from  thirty-six  hours  to  three 
or  four  days,  during  the  latter  part  of  which  the  body  be- 
comes slightly  icteroid.      In  severe  attacks  delirium  is  frequent. 

The  second  stage  is  that  in  which  the  fever  remits,  the  tem- 
perature declining  to  100°  or  99°  F.  All  the  distressing 
symptoms  abate  and  the  affection  may  terminate  by  crisis 
but  more  frequently  after  an  interval  varying  from  a  few 
hours  to  one  or  four  days  it  passes  into  the  third  stage. 

The  third  stage,  or  that  of  secondary  fever,  is  ushered  in  by 
a  return  of  all  the  symptoms  in  an  exaggerated  form,  followed 
by  jaundice,  which  passes  into  a  deep  mahogany  color,  black 
vomit,  hemorrhages  from  the  mucous  membranes,  feeble 
pulse,  cold  surface,  irregular  respiration,  and  death  from  ex- 


56  YELLOW  FEVER. 

haustion,  the  mind  remaining  clear  until  the  end.  Recovery- 
may  occur  even  after  the  appearance  of  black  vomit. 

Diagnosis. — According  to  Guiteras  the  distinctive  features 
of  this  disease  are :  Early  jaundice;  characteristic /ac-^Vs- ;  albu- 
minuria, which  shows  itself  even  in  mild  cases,  on  the  second, 
third,  or  fourth  day;  slowing  of  the  pulse  as  the  temperature 
rises,  most  noticeable  on  the  second  or  third  day;  and  a  high 
hemoglobin  estimate  (90  or  more)  at  the  beginning  of  the  disease. 

Dengue  may  be  mistaken  for  yellow  fever  but  it  lacks  the 
distinctive  features  just  enumerated.  In  view,  however,  of 
the  importance  of  the  subject,  as  well  as  of  the  possibility  of 
the  coexistence  of  dengue  and  yellow  fever,  the  following  table 
of  differential  diagnosis  (from  Jackson's  Tropical  Diseases)  is 
appended  (see  page  57). 

Remittent  fever  may  be  distinguished  by  the  presence  of  the 
malarial  microorganism  in  the  blood  and  the  therapeutic  test. 

Acute  yellow  atrophy  of  the  liver  resembles  yellow  fever 
closely  but  the  history,  pulse,  temperature,  and  presence  of 
leucin  and  tyrosin  in  the  urine  will  serve  to  differentiate 
the  former  from  the  latter. 

Prognosis. — The  disease  seldom  lasts  more  than  one  week. 
High  fever,  collapse,  black  vomit,  and  suppression  of  urine 
are  unfavorable  symptoms.  The  mortality  ranges  from  15 
to  85  per  cent.  According  to  Manson,  the  prognosis  is  better 
for  women  and  children  than  for  men;  better  for  old  residents 
than  for  new-comers;  worst  of  all  for  the  intemperate. 

Treatment. — The  spread  of  the  disease  should  be  prevented 
by  screening  the  apartments  of  infected  individuals  and  non- 
immunes by  ordinary  mosquito-netting.  Swamps  should 
be  drained  and  covered  with  insecticides,  such  as  tobacco  and 
petroleum,  and  the  population  of  infected  regions  should  be 
reduced  to  a  minimum. 

The  indications  are  to  keep  the  patient  quiet  in  bed  and 
to  treat  the  symptoms  as  they  arise.  Treatment  must  be 
begun  at  once;  there  is  no  time  to  be  lost.  The  fever  should 
be  reduced  by  cold-water  baths  or  packs,  or  sponging,  or  ice- 
bag,    or   cold   enemata.     The   coal-tar   derivative   antipyretics 


YELLOW   FEVER. 


57 


Temperature .  .  . 

Fever  of  one  paroxysm,  as 
a    rule.     High    tempera-; 
ture  for  3  days. 

Fever  of  two  parox- 
ysms and  a  remis- 
sion,    as    a     rule. 
Fever  high  in  first 
period;  low  in  sec- 
ond. 

Fever  of  several 
paroxysms  with 
remissions  or  in- 
termissions. Mod- 
erate temperature, 
as  a  rule. 

Duration      of 

fever. 

3  to  7  days 

5  to  8  days 

Variable  duration. 
May  last  weeks. 

Incubation 

Human  incubation,  i  to  6 
days.     Mosquito  incuba- 
tion about  1 2  days. 

Short  incubation,  i 
to  5  days;  average 
less  than  3  days.  . 

Human  incubation, 
I  to  several  days. 
Mosquito  incuba- 
tion, about  10  days. 

Vomiting 

Very  common  symptom — 
both    bilious    and    hem- 
orrhagic (black  vomit). 

Not  common.     Bil-    May  or  may  not  be 
ious    vomiting    in      present.        BiHous 
some  cases.                    in  character. 

Pulse 

At  first,  rapid  and  bound- 
ing;    later,      abnormally 
slow  and  soft.     Does  not 
correspond  with  tempera- 
ture. 

Corresponds      with 
febrile       tempera- 
ture. 

Corresponds      with 

febrile  tempera- 
ture. 

Jaundice 

Characteristic     and     con- 
stant. 

Rare 

Subicteric  jaundice 

rather  common. 

Eruptions 

Rare   and   not    character- 
istic. 

Common    and    dis- 
tinctive . 

Rare  and  not  char- 
acteristic. 

Urine 

Scanty ;   often   completely 
suppressed,  and  albumin- 
ous from  early  stages. 

Quantity        ample. 
Rarely      albvmiin- 
ous. 

Not    usually    albu- 

minous nor  sup- 
pressed. 

Mentality 

Apathy  common.         Con- 
sciousness preserved  as  a 
rule. 

Preserved 

Delirium     not     un- 

common. 

Hemorrhagic 
symptoms. 

Frequent  and  often  fatal. 
(Gastric     and     intestinal 
chiefly.) 

Of  rare  .  occurrence 
and  of  slight  con- 
sequence. 

Rare  except  in  per- 
nicious cases  and 
in  malarial  hemo- 
globinuria. 

Fatality 

Average  mortality  25    per 
cent. 

Non-fatal 

Rarely  fatal  if 
treated  properly. 

Convalescence.  . 

Rapid    and    without    se- 
quels. 

Rather  prompt  but 
with         arthralgic 
and     myalgia     se- 
quels. 

Slow,  succeeded  by 
anemia,  and  is  apt 
to  recur. 

Immunity 

One    attack    confers    sub- 
sequent immunity. 

Doubtful  immunity. 

No  immunity. 

Response     to 
treatment. 

Abortive  or  curative  treat- 
ment negative. 

Symptomatic  treat- 
ment alleviates. 

Satisfactory,  speci- 
fic (quinene)  treat- 
ment cures. 

Blood  condition. 

Incomplete        coagulation 
and    free   hemoglobin    in 
serum.       Red     cells    not 
greatly   altered.       White 
corpuscles  either  increas- 
ed or  decreased. 

Leukocytosis    com- 
mon. 

Decreased  _     leuko- 
cytes   claimed    by 
some  observers. 

Malaria  parasites 
and  pigment  pres- 
ent. Leucopenia 
with  a  relative 
increase  of  large 
mononuclear  leu- 
kocytes, the  rule. 

58  DENGUE. 

should  not  be  used.  The  irritability  of  the  stomach  permits 
of  ingestion  of  food  of  only  the  most  bland  character.  Mild 
laxatives  such  as  castor  oil,  calomel,  and  citrate  of  magnesia 
may  be  employed  in  the  early  stages.  Quinin  should  be  given 
hypodermically.  The  gastric  irritation  may  be  relieved  by 
cracked  ice,  carbolic  acid,  gr.  1/4  (0.016  gm.),  in  peppermint 
water,  milk  and  lime-water,  the  application  of  a  mustard 
plaster  over  the  epigastrium,  or — 

I^.      Hydrarg5n:i  chlor.  mitis. .    gr.  1/12  -005 

Morphine  sulphat gr.  1/20  .003 

M.  S. — Every  two  hours  until  nausea  is  controlled. 

Sternberg  advises : 

Tf.      Sodii  bicarb oijss  10.  gm. 

Hydrargyri  chloridi  corr.   gr.  1/3  .02  gm. 

AqucB  destillat Oij  950 .  c.c. 

M.  S. — Three  tablespoonfuls  every  hour. 

Stimulants  such  as  alcohol,  strychnin,  and  digitalis  should 
be  administered  to  support  the  patient,  and  the  hemorrhagic 
tendency  should  be  combated  by  Monsel's  solution,  acetate 
of  lead,  adrenalin  solution,  and  oil  of  turpentine.  Enter- 
oclysis  is  also  advised. 

The  serum  treatment  has  been  employed  by  Sanarelli  with 
questionable  success;  out  of  twenty-two  cases  so  treated, 
six  died. 

DENGUE. 

Synonyms. — Break-bone  fever;  dandy  fever.  The  word 
dengue  is  pronounced  dangay. 

Definition. — An  acute,  infectious,  epidemic,  febrile  disease, 
consisting  of  two  paroxysms  of  fever  with  an  intermission. 
The  first  paroxysm  is  characterized  by  high  fever,  distressing 
pains  in  the  joints  and  muscles,  and  a  peculiar  eruption;  the 
second  paroxysm  is  characterized  by  a  milder  fever,  an  eruption 
of  different  character  attended  with  intense  itching,  by  some 
recurrence  of  the  joint  pains,  and  by  debility. 

Cause. — The    specific  cause   is  still  undetermined;   but  it  is 


SCARLET   FEVER.  59 

believed  to  be  transmitted  by  the  bite  of  a  mosquito — Culex 
fatigans.  It  is  a  tropical  and  subtropical  disease,  of  great 
infectivity.      Incubation  from  two  to  five  days. 

Symptoms. — Onset  sudden — fever,  103°  to  105^^  F.,  intense 
headache,  burning  pains  in  the  temples,  backache,  severe  aching 
and  swelling  of  the  joints  and  stiffness  of  muscles,  nausea,  vomit- 
ing, constipation,  and  the  appearance  of  a  rash,  resembling 
scarlatina.  After  some  hours  to  two  or  or  three  days  a  dis- 
tinct intermission  of  one  or  two  days'  duration  takes  place. 

The  onset  of  the  second  paroxysm  is  also  sudden,  but  the 
symptoms  are  much  less  severe,  although  the  patient  is  greatly 
debilitated;  it  is  at  this  time  that  the  characteristic  erup- 
tion appears,  being  either  erythematous  or  roseolar  and  at- 
tended with  intense  itching,  remaining  for  about  two  days, 
when  desquamation  occurs  and  convalescence  is  established, 
but  is  prolonged  by  the  great  debility  of  the  patient.  En- 
largement of  the  lymph  glands  may  occur.  Average  dura- 
tion  of   the    disease   eight   days.      Relapses   are   common. 

Diagnosis. — The  history,  course,  paroxysmal  character, 
and  variability  of  the  eruption  will  distinguish  it  from  acute 
rheumatism,  scarlet  fever,  and  measles  which  it  may  some- 
times resemble.  For  differentiation  from  malaria  and  yellow 
fever,  see  the  table  on  page  57. 

Prognosis. — Recovery  is  the  rule. 

Treatment. — -There  is  no  special  treatment.  Isolation  and 
protection  from  mosquitos  should  be  observed.  The  symptoms 
should  be  treated  on  general  principles.  Tincture  of  gelsemium 
is  said  to  be  of  great  service.  Laxatives,  antipyretics,  and  anal- 
gesics are  often  indicated,  and  during  convalescence  tonics  should 
be  given.  The  patient  must  be  kept  warm  and  his  diet  should 
be  light  and  nutritious. 

SCARLET  FEVER. 

Synonym. — Scarlatina. 

Note. — Scarlatina  is  not  a  mild  form  of  scarlet  fever;  the 
two  terms  denote  exactly  the  same  disease. 

Definition. — An    acute,    self-limited,     contagious,     infectious 


6o  SCARLET   FEVER. 

disease,  characterized  by  high  temperature,  rapid  pulse,  a 
diffused  scarlet  eruption  terminating  with  desquamation, 
inflammation  of  the  mouth  and  throat,  a  tendency  to  nephritis, 
and  frequently  more  or  less  grave  nervous  phenomena. 

Cause. — It  is  due  to  a  special  microorganism  as  yet  unde- 
tected but  of  exceedingly  great  vitality.  It  retains  its  in- 
fecting power  for  at  least  one  year.  The  bearer  of  the  con- 
tagion is  in  all  probability  the  desquamated  epithelium  of  the 
infected  persons,  the  disease  being  particularly  communicable 
during  desquamation.  The  poison  is  disseminated  by  the  scaly 
particles  in  the  air,  clothes  or  other  fomites,  food,  etc.  The 
respiratory  tract  is  usually  the  route  of  infection  but  the  diges- 
tive tract  may  also  serve  to  carry  the  poison.  Children  are  most 
likely  to  contract  the  disease.  Second  attacks  are  very  uncom- 
mon but  may  occur. 

Pathologic  Anatomy. — There  are  no  characteristic  lesions. 
The  skin  is  the  seat  of  acute  inflammation  which  fades  away 
in  death.  The  liver,  spleen,  stomach,  kidneys,  heart,  and  mus- 
cles undergo  granular  changes.  The  throat  is  inflamed  and 
ulceration  sometimes  occurs. 

Symptoms. — The  incubation  period  is  short,  varying  from 
a  few  hours  to  a  week,  after  which  the  affection  manifests 
itself  in  one  of  three  forms,  simple,  anginoid,  and  malignant. 

The  onset  of  the  disease  is  sudden,  being  marked  by  a  chill, 
vomiting,  or  convulsions,  followed  by  pain  in  the  throat, 
high  fever,  105°  F.,  and  rapid  pulse,  no  to  140  beats  per 
minute.  At  the  end  of  twenty-four  hours  a  bright  scarlet 
rash  appears  on  the  neck  and  chest,  spreading  over  the  entire 
body  within  a  few  hours.  The  eruption  is  in  appearance 
like  a  boiled  lobster;  further,  it  is  not  raised,  and  disappears 
on  pressure.  Points  of  darker  hue  are  scattered  irregularly, 
but  there  is  no  intervening  healthy  skin,  the  rash  being  uni- 
formly distributed.  The  eruption  may  vary  at  times;  oc- 
casionally it  is  scarcely  visible;  in  some  instances  it  may  be 
slightly  papular  or  vesicular  (scarlatina  miliaris);  and  in 
malignant  cases  it  may  be  hemorrhagic  or  petechial.  As 
soon   as   it  is  complete  it  begins  to  fade,  seldom  lasting  more 


SCARLET   FEVER. 


6i 


than  five  days  or  a  week,  after  which  desquamation  begins 
and  occupies  from  two  to  six  weeks.  With  the  appearance 
of  the  rash  the  throat  symptoms  become  prominent.  Swallow- 
ing is  difficult,  there  are  pain  and  tenderness  in  the  throat  and 
jaws,  the  lymphatic  glands  are  swollen,  and  inspection  re- 
veals a  catarrhal  inflammation  of  the  pharynx  and  tonsils. 
A  punctiform  efflorescence  on  the  tonsils,  fauces,  and  pharyn- 
geal  vault   may   be   observed   before   the   rash   appears.     The 


107 


106 


^105 


104 


j2103 


1^ 
glD2 

101 


a. 


99 


98 


97 


m 


m 


i 


10 


FH=T^ 


-41 


-42 


o  g 

E 
>^ 

G 
-39°  K 


o    T> 

-38    3 


-37 


-rs 


Fig.    13. — Clinical  chart  of  scarlet  fever.      (From  Wilcox's  Fever  Nursing.) 

tongue  is  at  first  furred  and  later  red  with  prominent  papillas 
— the  "strawberry  tongue."  Headache,  restlessness,  and 
delirium  may  be  present.  Breathing  is  rapid.  The  appetite 
is  lost  and  the  bowels  are  usually  constipated  but  diarrhea 
is  not  uncommon.  The  urine  is  scanty,  high-colored,  and 
often  albuminous.  Leukocytosis  is  present.  The  fever  de- 
clines on  the  fourth  or  fifth  day  by  lysis.  The  duration  of 
simple  uncomplicated  cases  is  from  three  to  fourteen  days. 
Convalescence  is  slow. 

Anginoid  scarlet  fever  is  marked  by  a  predominance  of  the 


62  SCARLET   FEVER. 

throat  symptoms.  There  is  high  fever  and  great  exhaustion. 
Frequently  the  enlarged  glands  suppurate. 

Malignant  scarlet  fever  is  characterized  by  convulsions,  de- 
lirium, muscular  twitchings,  high  temperature,  107°  to  110°  F., 
rapid,  feeble,  and  irregular  pulse,  and  collapse.  The  eruption 
is  of  purplish  color  and  in  patches.  Death  may  occur  before 
its  appearance. 

Complications. — The  principal  complications  are  acute  neph- 
ritis, adenitis,  arthritis,  and  otitis.  Convalescence  may  be 
further  complicated  by  chronic  sore  throat,  diphtheria,  oph- 
thalmia, diarrhea,  otorrhea,  chorea,  endocarditis,  pericarditis, 
pleurisy,  and  suppuration  of  lymphatic  glands. 

Diagnosis. — The  distinctive  features  of  this  disease  are  the 
high  fever,  rapid  pulse,  sore  throat,  and  the  early  bright  scarlet 
eruption  with  its  subsequent  scaly  desquamation. 

Measles  differs  from  it  in  the  character  of  its  temperature, 
pulse,  and  eruption  and  is  marked  by  a  predominance  of 
catarrhal  symptoms. 

Diphtheria  resembles  the  anginoid  variety  but  may  be 
distinguished  by  the  absence  of  the  eruption  and  strawberry 
tongue  and  by  the  presence  of  the  false  membrane,  and  the 
Klebs-Loeffler  bacillus. 

Acute  tonsillitis  may  be  distinguished  by  the  absence  of  the 
characteristic  temperature,  pulse,  eruption,  strawberry  tongue, 
and  the  tendency  toward  nephritis. 

Meningitis  and  malignant  scarlet  fever  are  somewhat  simi- 
lar, but  the  history,  mode  of  onset,  pulse,  and  eruption  will 
serve  to  make  a  diagnosis. 

Erythema  scarlatinoides  has  several  points  in  common  with 
scarlatina,  but  may  be  distinguished  from  it  by  its  non-con- 
tagious nature,  the  mild  constitutional  disturbance,  the  ir- 
regular distribution  of  the  rash  (the  face  being  usually  free), 
desquamation  on  the  fourth  day,  the  absence  of  the  straw- 
berry tongue,  and  the  tendency  toward  recurrence. 

Drug  rashes  show  an  eruption,  but  present  no  fever  or 
other  symptom.  Belladonna,  quinin,  potassium  iodid,  chloral, 
and  acetanilid  are  the  chief  drugs  producing  a  rash. 


SCARLET   FEVER.  63 

Prognosis. — The  mortality  varies  from  5  to  10  per  cent, 
in  mild  epidemics,  to  20  to  30  per  cent,  in  severe  epidemics. 
The  occurrence  of  complications  adds  to  the  gravity  and  un- 
certainty of  the  case. 

Treatment. — Isolation,  rest  in  bed,  liquid  diet,  and  careful 
disinfection  of  all  the  sick-room  articles  is  highly  essential. 
The  patient  requires,  and  should  be  given,  jjlenty  of  cold 
water  to  drink.  The  fever  should  be  controlled  by  the  cold 
bath  (90°  F,  and  gradually  reduced),  douche,  pack,  or  cool 
sponging.  An  ice-bag  should  be  applied  to  the  head.  Drugs, 
such  as  citrate  of  potassium,  solution  of  ammonium  acetate, 
spirit  of  nitrous  ether,  and  tincture  of  aconite,  alone  or  com- 
bined, may  also  be  employed.  The  bowels  should  be  kept 
regular  by  the  administration  of  very  small  doses  of  calomel, 
soda,  and  ipecac,  combined.  Failing  circulation  will  indicate 
the  use  of  digitalis,  strychnin,  belladonna,  alcohol,  and  the  hot 
bath  or  pack. 

It  should  be  remembered  that  scarlet  fever  is  infectious  from 
the  first  day,  but  how  long  the  possibility  of  infection  may 
last  no  one  can  say.  The  child  should  be  isolated  for  not 
less  than  six  weeks  from  the  appearance  of  the  rash,  and 
should  not  then  be  allowed  to  mingle  with  other  people  unless 
apparently  quite  well  and  free  from  all  discharges  from  nose, 
throat,  and  ears.     Toys,  fomites,  etc.,  should  be  burned. 

With  the  appearance  of  the  eruption  the  body  should  be 
anointed  with  cold  cream,  cocoa-butter,  or  the  following: 

I^.      Eucalyptol f  5  j  4  .  c.c. 

Petrolat Bj  32  .  gm. 

M.  S. — Apply  locally  as  directed. 

In  anginoid  scarlet  fever  the  following  formula  will  be 
found  valuable: 

T^.      Tincturse  ferri  chlorid  .  .  .    f  5ij  8.  c.c. 

Glycerin f  oj  30  .  c.c. 

Aquae q.  s.  ad  f  §ij  ad       60 -.  c.c. 

M.  S. — One-half  to  one  tea.spoonful  every  two  hours,  undilu- 
ted, according  to  the  age. 


64  SCARLET   FEVER. 

Externally,  in  these  cases,  ice  and  cold  compresses  should 
be  employed  unless  they  produce  discomfort,  when  heat  should 
be  substituted.  Pellets  of  ice  allowed  to  dissolve  in  the  mouth 
often  produce  considerable  relief.  Dobell's  solution  should 
be  used  to   spray  the  nasal  fossag  and  pharynx  every  hour. 

I^.     Acid,  carbolici f  3iss  6.  c.c. 

Sodii  biboratis, 

Sodii  bicarb aa    3ij  8  .  gm. 

Glycerini f  §ij  60 .  c.c. 

Aquae q.  s.  ad  Oij  ad        950.  c.c. 

M.  S. — Dobell's  solution. 

The  following  gargle  may  also  be  employed  with  benefit : 

I^.     Thymol gr-  iv  .26  gm. 

Glycerin f  B j  30 .       c.c. 

Aq.  dest f  S  j  30 .       c.c. 

M.  S. — A  throat  wash,  dilute  if  necessary. 

Peroxid  of  hydrogen,  full  strength  or  diluted,  may  also  be 
used  to  antisepticize  the  mouth  and  throat. 

In  malignant  scarlet  fever,  stimulation  is  the  most  important 
feature  of  the  treatment.  Whiskey,  brandy,  iron,  quinin, 
and  strychnin  should  be  administered  to  their  physiologic 
limit. 

Convulsions,  restlessness,  tremors,  and  other  nervous  phe- 
nomena are  best  controlled  by  hydro  therapeutic  measures, 
but  the  use  of  bromids  and  choral  may  be  necessary  in  severe 
cases. 

Serum  treatment,  using  the  antistreptococcic  serum,  has 
been  employed  with  the  view  of  preventing  complications. 

Acute  nephritis  is  a  common  occurrence  in  scarlet  fever  par- 
ticularly after  desquamation,  in  the  second,  third,  and  fourth 
weeks.  The  urine  should  be  examined  daily  in  order  to  de- 
tect this  complication  as  early  as  possible.  Milk  diet,  digi- 
talis,   and    protection    of    the    patient    from   drafts   are   to   a 


SCARLET   FEVER.  65 

large  extent  preventive.     With  the  development  of  nephritis 
the  following  prescriptions  may  be  employed: 

I^.     Potassii  acetat 5ij  8 .  gm. 

Spts.  ffitheris  nitrosi.   .  .  .     gss  15.  c.c. 

Aquae q.  s.  ad    5ij  ad  60.  c.c.     . 

M.  S. — Teaspoonful  every  two  hours,  well  diluted. 

Or— 

I^.      Hydrarg3rri  chlor.  mitis, 

Pulv.  scillae,     . 

Pulv.  digital aa  gr.  1/4  to  1/2    .016  to  .032  gm. 

M.     Ft.  pil.  No.  3. 

S — One  such  pill  every  three  or  four  hours. 

Or— 

I^.     Potassii  acetatis, 

Potassii  bicarbonatis, 

Potassii  citratis aa   5ij  8  .   c.c. 

Infusi  tritici  repentis  q.  s.  ad  Bviij  240.   c.c. 

M.  S. — One  teaspoonful  every  three  or  four  hours  (for  a 
child  five  years  old). 

Saline  purgatives,  dry  cupping  over  the  loins,  warm  baths, 
hot  packs,  vapor  baths,  enteroclysis,  and  pilocarpin  will  be 
indicated  to  relieve  the  system  of  the  accumulated  poisons. 
Convulsions  will  require  the  use  of  chloral,  bromids,  sodium 
benzoate,  and  chloroform  in  addition. 

The  scarlatinal  arthritis  will  be  benefited  by  the  alternate 
administration  of  iron  and  the  following  mixture: 

I^.     Ammonii  salicylat 5ij  8  .  gm. 

Elix.  simplicis §ss  15  .  c.c. 

Syr.  simplicis •    Sj  30.  c.c. 

Tinct.  card,  comp §ss.  15.  c.c. 

M.  S. — Teaspoonful,  diluted,  foiir  times  daily. 

In   otitis,  the  application  of  a  hot  water  bottle  or  syringing 
the  canal  with   hot  water  will   serve  to  lessen  the  pain,   but 
should  the  tympanic  membrane  bulge  it  should  be  punctured 
to  allow  evacuation  of  any  confined  pus. 
5 


66  MEASLES. 


MEASLES. 


Synonyms. — Morbilli ;  rubeola. 

Definition. — An  acute  epidemic  and  contagious  disease; 
characterized  by  catarrhal  symptoms,  referable  to  the  naso- 
broncho-pulmonary  mucous  membrane,  fever,  and  a  crimson 
mottled,  papular  eruption  which  terminates  by  branny  des- 
quamation. 

Cause. — The  cause  is  an  unknown  microorganism  apparently 
associated  with  the  nasal  and  bronchial  secretions.  It  is 
transmitted  through  a  third  party,  also  through  clothes  and 
other  fomites.  Children  are  especially  predisposed  to  it,  but 
adults  may  be  attacked.  It  usually  occurs  in  epidemic,  but 
sporadic  cases  may  be  observed.  One  attack  usually  confers 
immunity,  but  second  attacks  are  not  very  uncommon. 

Pathologic  Anatomy. — There  are  no  characteristic  struc- 
tural changes.  Catarrhal  inflammation  of  the  entire  respiratory 
tract  is  almost  a  constant  accompaniment.  Gastrointestinal 
catarrh  may  also  be  present. 

Symptoms. — After  an  incubation  period  of  from  ten  to  four- 
teen days  the  disease  is  manifested  by  a  chill  or  chilliness, 
fever  ranging  from  ioi°  to  102°  F.,  muscular  soreness,  head- 
ache, and  intense  nasal,  pharyngeal,  and  laryngeal  catarrh. 
There  are  present  also  intolerance  to  light,  redness  and  water- 
ing of  the  eyes,  sneezing,  and  coughing.  On  the  second  day 
the  fever  remits  to  rise  again  on  the  fourth  day,  when  an 
eruption  of  small,  dark  red,  velvety  papules  arranged  in  cres- 
centic  groups,  appears  on  the  face  and  soon  spreads  over  the 
entire  body.  The  catarrhal  symptoms  still  persist.  The 
eruption  is  attended  by  itching  and  more  or  less  burning,  and 
about  the  ninth  day  begins  to  fade  and  disappear  entirely  by 
bran-like  desquamation.  All  the  symptoms  then  gradually 
ameliorate. 

Koplik  has  described  a  peculiar  eruption  consisting  of 
small  irregular  spots  of  a  bright  red  color,  each  having  a  blu- 
ish-white center,  which  appear  on  the  mucous  membrane 
of  the  lips  and  cheeks  on  the  first  day  of  invasion  and  which 


MEASLES. 


67 


he    believes    to    be    pathognomonic.      They    fade    away    with 
the    appearance  of  the  dermal  eruption. 

Black  measles,  hemorrhagic  measles,  or  malignant  measles 
is  that  variety  in  which  the  eruption  is  hemorrhagic  in  char- 
acter and  there  is  profound  prostration.  It  is  encountered 
in  camps,  jails,  and  other  places  in  which  the  hygiene  is  very- 
poor. 


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Fig.    14. — Clinical    chart   of   measles   showing  defervescence  by  lysis  beginning  when 
the  eruption  is  fully  developed.      {From  Wilcox's  Fever  Nursing.) 

Complications.— The  most  common  complications  are  ca- 
tarrhal pneumonia  and  gastroenteritis.  As  sequels  may 
be  mentioned  tonsillitis,  tuberculosis,  ophthalmia,  and  cancrum 
oris. 

Diagnosis. — The  characteristic  features  of  measles  are 
its  gradual  onset,  often  with  drowsiness,  chilliness,  nasal 
catarrh,  watery  eyes,  fever  which  declines  on  the  second  day 
to  rise  on  the  fourth,  the  appearance  of  a  crimson  papular 
eruption  on  the  fourth  day  preceded  by  Koplik's  spots  on  the 
first  day,  and  the  bran-like  desquamation. 


68  MEASLES. 

Scarlet  fever  may  be  distinguished  by  the  absence  of  Koplik's 
spots  and  the  difference  in  the  date  and  character  of  the 
eruption,    pulse,  temperature,  and  symptoms. 

German  measles  or  rotheln  may  be  diagnosed  by  the  differ- 
ence in  the  eruptions  and  the  absence  of  constitutional 
manifestations . 

Pityriasis  rosea  resembles   measles   somewhat,  but   its   rose- 
colored   erythemato-squamous   and   papular   patches   are   con 
fined  to  the  trunk  and  there  are  no  constitutional  disturbances 
as  a  rule.     It  is  of  longer  duration. 

Prognosis. — Nearly  all  uncomplicated  cases  recover.  Lung 
complications  are  always  of  serious  import.  In  black  meas- 
les, the  majority  succumb. 

Treatment. — Isolation,  rest  in  bed,  and  protection  from 
drafts  and  from  bright  light  are  necessary  from  the  onset  of 
the  disease.  It  is  often  desirable  to  give  a  diaphoretic  mixture, 
such  as  the  following: 

I^.     Potassii  nitratis 3j  4.     gm. 

Liquoris  ammonii  acetatis .      Sij  60.     c.c, 

Vini  ipecacanhae nxxxxvj  2  .  5  c.c. 

S5rrupi  limonis 5vj  24.     c.c. 

Aquae q.  s.  ad    §vj  180.      c.c. 

M.  S. — One  to  two  tablespoonfuls  every  four  or  five  hours. 

The  bowels  should  be  kept  regular  by  means  of  some  mild 
laxative.  The  diet  should  be  semisolid.  Mild  cases  require 
no  medicines.  Cool  sponging  or  the  following  will  reduce 
the  temperature  when  it  becomes  alarmingly  high: 

I^.     Tinct.  aconiti nxijtoiv  .  12  to  .24  c.c. 

Spts.  aetheris  nitrosi rr^xto  xv  .  6  to  i .       c.c. 

Liq.  potas.  citrat.  q.  s.  ad  f  5 j  4 .                   c.c. 
M.  S. — Every  two  hours. 

Daily  inunctions  of  cold  cream,  cocoa-butter,  eucalyptol 
in  petrolatum,  and  similar  oily  substances  will  serve  to  relieve 
the  itching  of  the  eruption.  Camphorated  oil  rubbed  on  the 
chest  and  applied  to  the  nose  and  neck  aids  in  lessening  the 
catarrhal  symptoms. 


RUBELLA.  69 

During  convalescence  iron,  strychnin,  quinin,  cod-liver 
oil,  syrup  of  the  iodid  of  iron,  and  similar  tonics  should  be 
advised. 

Black  measles  requires  constant  stimulation  in  addition 
to  other  measures.  The  various  symptoms  should  be  treated  as 
they  arise. 

RUBELLA. 

Synonyms. — Rotheln;  epidemic  roseola;  German  measles; 
French  measles;  false  measles. 

Definition. — An  acute,  self -limited,  contagious  disease;  char- 
acterized by  mild  fever,  suffused  eyes,  cough,  sore  throat, 
enlargement  of  the  lymphatic  glands  of  the  neck,  and  a  rose- 
colored  eruption,  in  patches  of  irregular  size  and  shape,  ap- 
pearing on  the  first  day. 

Many  so-called  second  attacks  of  measles  and  scarlet  fever 
are  attacks  of  rubella  (Tyson). 

Cause. — The  disease  is  due  to  some  special  microorganism 
as  yet  undiscovered.  It  may  be  epidemic  or  sporadic.  The 
contagion  is  disseminated  by  clothes  and  other  fomites.  Child- 
hood is  a  predisposing  factor.  One  attack  usually  confers 
immunity. 

Symptoms. — The  onset  is  sudden  with  mild  fever,  suffused 
e5^es,  little  or  no  coryza,  sore  throat,  enlargement  of  the  cer- 
vical glands,  and  an  eruption  of  rose-colored,  pin-head-sized 
spots  which  appear  any  time  from  the  first  to  the  fourth  day. 
All  the  symptoms  disappear  within  a  week  by  lysis. 

Prognosis. — Recovery  is  almost  constant. 

Treatment. — There  is  no  special  treatment;  the  measures 
indicated  under  measles  are  applicable  to  this   disease. 

SMALL-POX. 

Synonym. — Variola . 

Definition. — An  acute  epidemic  and  contagious  disease; 
characterized  by  severe  lumbar  pains,  vomiting,  and  an  initial 
fever,  lasting  from  three  to  four  days,  followed  by  an  eruption 


70  SMALL-POX. 

which  passes  through  the  stages  of  macule,  papule,  vesicle, 
and  pustule;  the  development  of  the  pustule  being  accom- 
panied by  a  secondary  fever  during  the  presence  of  which  grave 
complications  are  prone  to  occur. 

Causes. — Probably  an  intracellular  parasitic  protozoon,  the 
Cytoryctes  variolce;  it  maintains  its  contagious  vitality  for  a 
long  period.  There  is  no  period,  from  the  initial  fever  to  the 
final  desquamation,  when  the  disease  is  not  contagious, 
although  the  stage  of  suppuration  is  the  most  virulent.  One 
attack,  as  a  rule,  protects  from  a  second.  Vaccination 
has  a  positive  protective  influence  from  the  disease,  an  ex- 
tensive observation  having  fully  proven  that  in  proportion 
to  the  efficiency  of  vaccinati6n  is  the  rarity  and  mildness  of 
variola. 

Pathologic  Anatomy. — The  eruption  (with  its  four  stages 
of  macule,  papule,  vesicle,  and  pustule)  is  the  only  distinc- 
tive pathological  lesion.  The  depression  in  the  center  of 
the  pustule  corresponds  to  the  area  of  primary  necrosis.  A 
granular  and  fatty  degeneration  occurs  in  the  liver,  spleen, 
kidneys,  and  heart.  The  pustules  are  found  in  the  larynx, 
trachea,  bronchial  tubes,  and  on  the  pleura. 

Varieties. — Three   forms   of   the    disease   are    described: 

(i)  Variola  vera,  or  simple  small-pox,  which  may  be  (a) 
discrete  or  (b)  confluent. 

(2)  Variola  hemorrhagica,  hemorrhagic  or  malignant  small- 
pox. 

(3)  Variola  benigna,  or  varioloid,  or  small-pox  modified  by 
vaccination. 

Symptoms. — The  manifestations  of  small -pox  are  preceded 
by  an  incubation  period  which  varies  from  seven  to  fifteen 
days. 

In  the  discrete  form  the  onset  is  sudden  with  a  violent 
chill,  vomiting,  intense  headache,  and  agonizing  pains  in  the 
back  shooting  down  the  limbs.  In  children  the  chill  may 
be  replaced  by  one  or  more  convulsions.  The  temperature 
rises,  reaching  103°  to  104°  F.  within  a  short  time. 

The  pulse  is  full,  strong,  and  rapid,  ranging  from  100  to  130. 


SMALL-POX.  71 

The  face  is  red  and  the  eyes  are  injected.  Intense  headache, 
sleeplessness,  delirium,  and  convulsions  may  and  often  are 
present.  Prostration  is  profound.  On  the  third  day  the 
characteristic  eruption  appears  first  on  the  forehead  and  lips, 
consisting  of  coarse  red  spots.  It  may  be  preceded  by  a  diffuse 
scarlatinous  or  measly  rash  (sometimes  petechial  in  character) 
most   marked   on   the   inner   surface   of   the   arms   and  thighs. 

The  true  eruption  becomes  distinctly  papular  within  twenty- 
four  hours  and  the  lesions  acquire  shot-like  hardness.  With 
the  appearance  of  the  eruption  all  the  symptoms  abate,  the 
temperature  falls  several  degrees,  and  the  patient  feels  quite 
comfortable.  On  the  sixth  day  of  the  disease  the  papules 
become  converted  into  umbilicated  and  loculated  vesicles, 
and  on  the  eighth  or  ninth  day  these  lose  their  umbilication 
and  become  mature  pustules,  each  surrounded  with  a  broad 
red  band.  The  temperature  again  rises  and  the  symptoms 
reappear  at  this  period.  There  is  marked  edema  of  the  skin 
between  the  lesions,  causing  swelling  of  the  surface  and  ren- 
dering the  features  unrecognizable.  The  tension  of  the  pus- 
tules induces  localized  pains  particularly  in  the  face;  the 
eyelids  become  swollen  and  closed.  On  the  tenth  or  eleventh 
day  the  pustules  begin  to  dry  up  and  are  converted  into  scabs 
or  crusts  by  the  fourteanth  day.  These  emit  a  peculiar  offen- 
sive odor  and  fall  off  from  the  seventeenth  to  the  twenty- 
first  day  leaving  a  red  glistening  depression  or  pit  which  later 
changes  into  a  white  cicatrix.  The  secondary  fever  lasts 
about  three  or  four  days,  in  favorable  cases  terminating  by  lysis. 

Confluent  small-pox  is  characterized  by  early  appearance 
of  the  eruption,  coalescence  of  the  pustules  (chiefly  on  the 
face),  marked  prostration,  delirium,  stupor,  high  and  irregu- 
lar secondary  fever,  swelling  of  the  surface,  and  distortion  of 
the  features.  Convalescence  is  tedious  and  disfiguring  sequels 
are  common  in  most  favorable  cases. 

Malignant  or  hemorrhagic  small-pox  consists  in  the  appear- 
ance of  widely  distributed  purpuric  spots  before  the  true 
eruption  or  in  the  occurrence  of  hemorrhages  into  the  mature 
pustules.      Bleeding  from  the  mucous  membranes  is  common. 


72 


SMALL-POX. 


The  onset  is  usually  sudden  and  violent;  all  the  symptoms  are 
intensified.  This  variety  is  also  known  as  black  small-pox 
and  is  nearly  always  fatal. 

Varioloid  is  that  modified  variety  of  small-pox  which  occurs 
in  vaccinated  individuals  or  those  who  have  previously  been 
attacked.  Its  course  is  shorter  and  milder  than  other  forms, 
the  eruption  appears  later,  there  is  no  secondary  fever,  the 
pocks  are  smaller,  and  there  is  little  or  no  pitting. 


DAY  OF 

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Fig  15. — Clinical  chart  of  small-pox  showing  fall  of  temperature  upon  the  appearance 
of  the  eruption  and  its  rise  upon  the  incidence  of  the  stage  of  pustulation.  {From 
Wilcox's  Fever  Nursing.) 


Complications. — During  the  course  of  the  secondary  fever 
there  is  a  great  tendency  toward  pleurisy,  bronchopneumonia, 
laryngitis,  and  dysentery.  During  convalescence  boils,  ab- 
scesses, ulcerative  eye-diseases,  otitis,  neuritis,  and  arthritis  are 
prone  to  develop. 

Diagnosis. — The  characteristic  features  of  this  disease  are 
the  remittent  type  of  fever,  sudden  onset  with  chill,  vomiting, 


SMALL-POX.  73 

and  excruciating  pains  in  the  back  and  legs,  and  the  appear- 
ance of  a  papular  eruption  on  the  third  day  which  later  be- 
comes vesicular  and  then  pustular. 

In  measles  the  initial  symptoms  are  less  severe,  the  pain 
in  the  back  is  never  so  excruciating;  the  coryza,  photophobia, 
cough,  and  Koplik's  spots  are  all  very  characterstic  of  measles. 
Further,  the  fever  does  not  subside  after  the  eruption  appears. 

Varicella  may  resemble  variola,  but  the  constitutional 
symptoms  are  less  severe  and  the  eruption  which  is  essentially 
vesicular  appears  on  the  first  day  coming  out  in  crops.  The 
lesions  dry  up  within  two  or  three    days. 

Syphilis  may  be  distinguished  by  its  history,  the  poly- 
morphous character  of  the  eruption  and  its  symmetric  dis- 
tribution, the  adenopathy,  the  alopecia,  and  the  mild  con- 
stitutional symptoms. 

Scabies  is  attended  by  papules  and  pustules  and  may  simu- 
late the  eruption  in  mild  cases  of  variola.  The  presence  of 
the  itch-mite  between  the  fingers  will  serve  to  make  the 
diagnosis. 

Prognosis. — This  depends  upon  the  variety  of  the  attack, 
the  age  of  the  patient,  and  the  presence  or  absence  of  vacci- 
nation. In  unprotected  persons  the  death  rate  is  from  2  5  to 
35  per  cent.;  in  the  malignant  form  all,  or  almost  all,  perish. 
In  those  under  five  years  of  age  and  over  forty  years  the  mor- 
tality is  50  per  cent.,  and  in  unvaccinated  individuals  it 
ranges  from  20  to  60  per  cent.  The  mortality  of  varioloid  is  a 
little  over  i  per  cent. 

Treatment. — Compulsory  vaccination,  properly  "  carried  out, 
would  prevent,  if  not  entirely  exterminate,  small-pox.  As  in 
other  contagious  diseases,  isolation,  ventilation,  cleanliness, 
and  disinfection  are  imperative.  The  patient  should  be  con- 
fined to  bed  in  a  darkened  room,  the  average  temperature 
of  which  is  65°  F.  The  diet  should  consist  of  milk,  eggs, 
animal  broths,  oysters,  beef -juice,  and  similar  foods  admin- 
istered every  three  hours  from  the  onset.  If  vaccination  has 
not   already  been   performed,   the   patient  should  be  immedi- 


74  SMALL-POX. 

ately  vaccinated,  as  it  may  possibly  modify  the  attack.  The 
initial  fever  and  the  accompanying  symptoms  may  be  relieved 
by  phenacetin,  gr.  x  (0.65  gm.),  antifebrin,  gr.  v  (0.32  gm.), 
acetanilid,  gr.  v  to  x  (0.32  to  0.65  gm.),  or  antipyrin,  gr.  x 
(0.65  gm.),  repeated  as  the  occasion  requires  it,  avoiding  de- 
pression. Headache  may  be  controlled  by  the  application  of 
sinapisms  to  the  neck  and  an  ice-bag  to  the  head.  Sleeplessness, 
restlessness,  and  delirium  indicate  the  employment  of  the  bro- 
mids,  trional,  chloral,  or  opium.  The  irritability  of  the  stomach 
may  be  overcome  by  ice  pellets  allowed  to  dissolve  in  the 
mouth  and  the  administration  of  dilute  hydrocyanic  acid 
(iTLij).  Excessive  diarrhea  may  be  controlled  by  camphor- 
ated tincture  of  opium,  bismuth  subnitrate,  or  lead  acetate 
with  opium.  With  the  onset  of  the  secondary  fever,  quinin, 
tincture  of  the  chlorid  of  iron,  and  brandy  should  be  admin- 
istered in  full  doses.  Tincture  of  aconite  is  also  useful.  Hy- 
drotherapy should  be  used  to  combat  high  temperature.  The 
mouth  and  nasopharynx  should  be  cleansed  with  Dobell's 
solution  (for  composition,  see  page  64.)  and  all  crusts  should 
be  carefully  removed,  and  boric  acid  lotion  should  be  employed 
to  irrigate  the  conjunctival  sac. 

To  prevent  pitting  the  patient  should  be  kept  in  the  dark 
and  covered  with  some  unctuous  material  or  with  cold  wet 
dressings  of  bichorid  of  mercury  (i  :  5000  to  i  :  1000)  or  car- 
bolic acid  (10  gr.  to  the  ounce).  Hot-water  dressings  may  be 
more  gratefully  received.  Painting  of  the  pustules  with  ich- 
thyol,  5  to  20  per  cent.,  is  also  recommended.  Scham- 
berg  advises  painting  with  iodin.  A  lotion  consisting  of 
picric  acid  (30  gr.),  alcohol  (1/2  ounce),  and  water  (61/2 
ounces)  has  also  been  recommended.  Collodion  is  sometimes 
employed.  When  wet  dressings  are  undesirable  eucalyptol 
in  petrolatum  (5i  tp  Si)  or  carbolic  acid  and  lanolin  (gr.  x 
to   3i)  may  be  applied. 

Among  the  special  forms  of  treatment  may  be  mentioned 
the  Finsen  red-light  treatment,  the  internal  antiseptic  treat- 
ment, and  antiseptic  baths. 


VACCINATION.  75 

VACCINATION. 

Synonyms.- — Vaccinia;  cow-pox. 

Definition. — The  reaction  which  follows  inoculation  with 
the  vaccine  virus  or  virus  of  cow-pox.  It  furnishes  almost 
complete  immunity  against  small-pox.  It  should  be  per- 
formed in  infancy,  at  puberty,  and  whenever  small-pox  is 
prevalent. 

Nature  of  Vaccinia. — There  are  two  views:  (i)  that  it  is 
small-pox  modified  by  transmission  through  the  cow;  (2) 
that  it  is  a  separate  disease,  distinct  from  small-pox.  The  ques- 
tion is  not  settled,   but  the  former  view  is  probably  correct. 

Etiology. — Unknown,  but  probably  a  protozoon — the  Cy- 
toryctes    vaccinics . 

Lymph  in  Use. — Animal  lymph,  a  lymph  from  the  cow,  is  now 
almost  universally  used,  but  humanized  lymph  can  also  be  used. 

Value  of  Vaccination. — There  can  be  no  doubt  that  compul- 
sory vaccination  would  prevent,  if  not  actually  exterminate, 
small-pox.  "The  German  army  since  1874,  the  date  of  the 
stringent  laws,  has  enjoyed  practical  immunity — not  a  single 
death  from  small-pox  (to  the  date  of  the  last  report,  1902), 
except  an  isolated  case  under  peculiar  circumstances  in  1884- 
85"    (Osier). 

Technic. — The  area  selected  should  be  carefully  cleansed 
with  soap  and  water  and  alcohol.  The  skin  should  be  scratched 
and  cross-scratched  with  an  aseptic  needle  or  special  scarifier, 
being  careful  not  to  produce  bleeding  but  instead  merely  ooz- 
ing of  pinkish  serum.  The  virus  is  then  rubbed  in  by  means 
of  the  needle  or  scarifier  making  additional  scratches. 

Symptoms. — Successful  vaccination  will  be  manifested  on 
the  third  day  by  a  papule  which  becomes  a  vesicle  on  the 
sixth  day  and  a  pustule  on  the  eighth  day  surrounded  by  a 
reddish  areola.  The  adjacent  tissues  are  red  and  infiltrated. 
Tenderness  and  itching  are  also  present.  The  areola  begins 
to  fade  on  the  tenth  day,  and  the  pustule  is  converted  into  a 
mahogany-brown  crust  by  the  fourteenth  day  becoming  de- 
tached  about    the    twenty-third    day.     The    resultant    scar   is 


76  VACCINATION. 

circular,  depressed,  foveated,  radiated,  and  paler  than  the  sur- 
rounding integument.  In  some  cases  slight  fever,  malaise, 
restlessness,  glandular  enlargement,  and  other  constitutional 
symptoms  are  present. 

Complications. — Infection  may  occur  resulting  in  abscess, 
erysipelas,  or  tetanus.  Occasionally  the  eruption  may  be 
generalized.  Sometimes  it  is  followed  by  various  eruptions 
resembling  roseola,  rubeola,  urticaria,  eczema,  erythema  mul- 
tiforme,   and   similar  affections. 

Syphilis  and  tetanus  have  been  transmitted  by  vaccination; 
that  tuberculosis  and  leprosy  have  been  so  transmitted  has 
been  claimed  but  never  proved.  Hence  the  most  scrupulous 
care  should  be  observed  in  the  preparation  of  the  animal 
virus  and  all  antiseptic  and  aseptic  precautions  should  be 
taken  in  performing  vaccination. 

Tyson  truly  says:  "It  is  exceedingly  important  that  the 
physician  should  have  at  hand  the  data  of  discriminating  be- 
tween the  ulcer  of  vaccinosyphilis  and  of  vaccination  and  be- 
tween secondary  vaccinosyphilis,  the  vaccination  rashes,  and 
hereditary  syphilis  occurring  about  the  time  of  vaccination. 
Such  data  are  found  in  the  following  tables:" 

Vaccinosyphilis  or  vaccino-chancre.        |  Vaccination  ulcers. 


Chancre  developed  on  the  site  of  usually  Ulceration  affects  all   the    punctures,   as  a 

one    or    two    only    of    the    vaccination         rule. 

punctures. 

Inflammation  is  slight ;  Inflammation  and  ulceration  severe. 

Loss  of  substance  superficial  only j  Ulcer  deeply  excavated. 

Suppuration  scanty  or  absent,   scabs,   or  [Much  suppuration. 

crusts.  ' 

Border  of  chancre   smooth,   slightly  ele-  Margin    of    ulcer    irregular,    as     in     "soft 

vated,  gradually  merging  into  floor.  :      chancre." 


Surface  of  floor  smooth 

Induration  "  parchment-like,"  and  specific, 

not  merely  inflammatory. 

Inflammatory  areola  very  slight 

Gland  swelling  constant,  indolent   (syph- 

iUtic)  bubo. 
Complications  rare 


Floor  of  ulcer  uneven,  suppurating. 
Induration  inflanunatory  only. 


Areola  inflammatory  and  erysipelatous. 

Gland    swelling   often   absent;    if    present, 
merely  inflammatory. 

CompUcations — sloughing,    erysipelas,    etc. 

j      —  often  present. 

Chancre  never  developed  before  the  fif-    Ulceration    is    present    twelve     to     fifteen 
teenth   day   after   vaccination;   usually  |      days     after     vaccination     and     is     fully 
not  luitil  after  three  to  five  weeks;  it   1     developed   the   twelfth   day  after  vacci- 
is  still  in  its  earlier  stage  twenty  days  '•     nation. 
after  vaccination.  ! 


VARICELLA. 


77 


Secondary     syphilitic     eruption     due     to 
vaccinosyphilis. 


Vaccination  rashes. 

(Including  roseola  vaccinalis,  miliaria  vac- 
cinalis,  vaccinia  bullosa,  vaccinia  hasm- 
orrhagica;  also  accidental  eruptions — 
rubeola,  scarlatina,  lichen,  urticaria,  etc.) 


Appears,  at  the  earliest,  nine  or  ten  weeks    A  true   vaccinal   rash  appears  between  the 
after  vaccination.  ninth  and  fifteenth  day  after  vaccination. 

Requires,  in  every  case,  the   preexistence    Absence  of  inoculation  chancre, 
of  a  specific  ulcer  (chancre)  at  the  site  \ 
of  vaccination. 

Exhibits  the  character  of  a  true  specific    Eruption   does   not   exhibit    specific    char- 
eruption,  acters. 

Fever  often  slight Fever  always  present. 

Lasts  for  a   long  time.     Usually  accom-    Evanescent, 
panied     by     specific     appearances     on 
mucous  membranes.  i 


Vaccinosyphilis. 


Hereditary  syphilis,   showing  itself  about 
the  time  of  vaccination. 


Begins  with  local  infection  chancre  and 

indolent  bubo. 
Typical  development  in  four  stages — viz., 

incubation,  chancre,  second  incubation, 

generaKzation      (secondary     eruption) , 

etc. 
Never  appears  earlier  than  the  ninth  or 

tenth  week  after  vaccination. 


No  chancre;  begins  with  general  phe- 
nomena. 

Has  no  typical  development  in  connection 
with  vaccination. 


Time  of  development  quite  independent 
of  vaccination.  Is  attended  by  the 
characteristic  syphihtic  bodily  aspects. 
Other  manifestations  of  hereditary 
syphilis  may  be  present.  The  history 
may  indicate  syphilis. 


VARICELLA. 

Synonym, — Chicken-pox. 

Definition. — A  mild,  contagious,  febrile  affection;  character- 
ized by  a  moderate  fever,  and  the  appearance  of  a  vesicular 
eruption  which  drys  up  and  falls  off  in  from  three  to  five  days. 
Its  cause  is  unknown.     Children  are  most  often  attacked. 

Symptoms. — About  two  weeks  usually  elapses  between  the 
period  of  infection  and  the  onset  of  the  disease  which  is  mani- 
fested by  moderate  fever,  thirst,  anorexia,  and  constipation. 
The  eruption  occurs  within  twenty-four  hours  at  first  being 
red  spots  which  are  rapidly  converted  into  clear  vesicles.  The 
vesicles  are  not  umbilicated  or  loculated,  and  appear  in  crops. 


78  ERYSIPELAS. 

Itching  is  intense.  The  lesions  are  most  abundant  on  the 
trunk ;  they  dry  rapidly,  dropping  off  within  a  week,  sometimes 
with    pitting.      Very   rarely   the   vesicles   become    gangrenous. 

Diagnosis. — The  slight  constitutional  disturbances  and  the 
superficial  and  non-umbilicated  pocks  distinguish  varicella 
from  small-pox. 

The  disease  nearly  always  terminates  favorably  and  without 
complications,  so  that  treatment  is  unnecessary  except  possibly 
to  relieve  aggravated  symptoms.  For  the  itching,  a  solution 
of  phenol  (1:40)  may  be  sponged  on  the  skin  several  times  a 
day. 

ERYSIPELAS. 

Synonyms. — The  rose;  St.  Anthony's  fire. 

Definition. — An  acute,  specific,  infectious  disease;  character- 
ized by  more  or  less  severe  febrile  reaction  and  a  peculiar  in- 
flammation of  the  skin  generally  of  the  neck  and  face.  This 
inflammation  exhibits  a  marked  tendency  to  spread,  to  induce 
serous  infiltration  and  suppuration  of  the  areolar  tissue,  and 
to  affect  the  lymphatic  vessels  and  glands.  Recurrences  are 
common. 

Cause. — The  exciting  cause  is  the  streptococcus  erysipelatis, 
a  microorganism  which  is  not  distinguishable  from  the  strep- 
tococcus pyogenes.  Lowered  vitality,  existence  of  abrasions 
and  wounds,  and  the  puerperal  state  are  predisposing  factors. 
It  is  contagious,  and  one  attack  predisposes  to  subsequent  at- 
tacks.    The  incubation  period  varies  from  two  to  seven  days. 

Pathologic  Anatomy. — The  disease  consists  essentially  of 
a  septic  inflammation  of  the  skin  and  subcutaneous  tissues, 
most  frequently  observed  on  the  face  and  often  directly  trace- 
able to  some  intranasal  affection.  Pyemic  abscesses  of  the 
internal  viscera  may  be  found,  as  well  as  infarcts  in  the  lungs, 
spleen,  and  kidneys. 

Symptoms. — The  physician  generally  sees  the  so-called  idio- 
pathic erysipelas,  which  arises  independently  of  any  apparent 
traumatic    lesion.     The    onset    is    sudden    with    chill,    nausea, 


ERYSIPELAS.  79 

vomiting,  or  convulsions,  malaise,  headache,  pains  in  the  limbs, 
and  a  rise  of  temperature,  104°  to  105°  F.  There  is  a  corre- 
sponding increase  in  the  pulse  rate.  The  tongue  is  coated  and 
there  may  be  diarrhea  or  constipation.  The  urine  is  scanty, 
albuminous,  and  high-colored.  Delirium  is  frequent  and  in 
alcoholics  resembles  delirium  tremens.  Examination  of  the 
blood  reveals  a  marked  leukocytosis. 

The  eruption  soon  follows  the  initial  chill  and  appears  as  red 
spots  which  rapidly  coalesce  forming  a  tense,  crimson  or  violet- 
hued,  shining  area.  This  area  is  swollen  and  firm,  is  hot  and 
tender  to  the  touch,  and  has  a  sharply  defined  border.  Vesicles 
and  blebs  frequently  develop.  The  pat  ent  complains  of  heat, 
tingling,  burning,  and  itching  in  the  affected  tissues.  The 
edema  of  the  surrounding  parts  is  marked  and,  when  the  face 
is  involved,  distorts  the  features.  The  eruption  begins  to  sub- 
side after  five  or  six  days  followed  by  moderate  desquamation 
and  decline  of  the  fever  by  lysis.  When  the  eruption  is  at- 
tended by  marked  infiltration  of  the  areolar  tissues  the  term 
phlegmonous  erysipelas  is  employed.  When  the  affection  is 
migratory  in  character,  disappearing  in  one  place  and  appearing 
in  another,  it  is  called  erysipelas  ambulans. 

Complications. — Complications  are  uncommon.  Thrombo- 
sis of  the  cerebral  vessels,  edema  of  the  larynx,  septicemia, 
pneumonia,  endocarditis,  pleurisy,  pericarditis,  and  rheumatism 
have  been  observed  in  the  course  of  this  disease. 

Diagnosis. — The  irregular  fever,  the  early  spreading  eruption 
with  burning,  swelling,  tension  and  a  sharply-defined  border, 
and  the  albuminous  urine  will  distinguish  erysipelas  from  the 
eruptive  fevers,  eczema,  and  erythema.    . 

Prognosis. — The  outlook  is  favorable  except  in  alcoholics, 
puerperal  women,  infants,  and  debilitated  subjects;  it  is  also 
worse  in  the  migratory  form  of  the  disease. 

Treatment. — Patients  with  erysipelas  should  be  isolated, 
particularly  from  all  surgical  and  obstetrical  cases.  The  dis- 
ease is  self-limited,  and  many  cases  of  the  so-called  idiopathic 
erysipelas  get  well  without  any  treatment  whatever.  In  mild 
cases    the    internal  administration  of  a  laxative  and  the  tine- 


8o  MUMPS. 

ture  of  the  chlorid  of  iron  with  the  local  application  of  vaselin, 
chthyol  ointment  (3i  to  Bi),  or  bismuth  oleate  will  suffice. 
In  severe  cases  the  patient  should  be  supported  by  the  use  of 
quinin  sulphate,  gr.  ii  (0.13  gm.),  extract  of  belladonna,  gr.  1/4 
{0.016  gm.),  and  tincture  of  the  chlorid  of  iron,  tt]^x  to  xx  (0.6 
to  1.3  c.c.)  every  third  hour.  A  liquid  but  nutritious  diet 
should  be  ordered.  Alcohol  may  be  required,  particularly  in 
the  old  and  feeble.  Nervous  symptoms  should  be  combated 
with  appropriate  measures  as  they  arise. 

In  the  early  stages  there  may  be  used  pilocarpin  hydro- 
chlorid,  gr.  1/6  (0.0 11  gm.),  hypodermically  or  fiuidextract 
of  pilocarpin,  tt^xx  to  xxx  (1.3  to  2  c.c),  every  three  hours 
until  free  sweating  occurs;  after  this  the  interval  should  be 
increased  to  six  hours.  lodid  of  potassium  and  the  antistrep- 
tococcic serum  have  also  yeilded  good  results 

Local  Treatment. — Peroxid  of  hydrogen,  glycerite  of  boro- 
glycerin,  lead-water  and  laudanum  (4  parts  of  liquor  plumbi 
subacetatis  dilutus,  U.  S.  P.,  to  2  of  laudanum),  carbolic  acid 
lotion  (3ii  to  the  pint),  or  silver  nitrate  solution  (gr.  xx  to  the 
ounce)  may  be  applied.  Ointments  containing  ichthyol,  zinc 
oxid,  mercurial  ointment,  eucalyptol,  or  soluble  silver  are  also 
beneficial.  The  application  of  tincture  of  iodin  or  solid  silver 
nitrate  to  the  periphery  often  checks  extension  of  the  disease. 
In  deep-seated  varieties,  scarifying  and  multiple  incisions  will 
be  necessary. 

MUMPS. 

Synonym. — Parotitis. 

Definition. — An  acute,  specific,  infectious  inflammation  of 
one  or  both  parotid  and  other  salivary  glands  and  the  sur- 
rounding connective  tissue,  with  a  tendency  to  migrate  into  the 
testes  or  mammae,  characterized  by  pain,  swelling,  and  disor- 
dered function  of  the  glands.     The  affection  is  contagious. 

Causes. — The  specific  cause  is  at  present  unknown.  It 
occurs  in  epidemics,  although  isolated  cases  are  seen.  Males 
are  more  liable  than  females.     The  most  common  ages  are  be- 


MUMPS.  8l 

tween  five  years  and  puberty.  As  a  rule  it  occurs  but  once 
in  the  same  individual.  The  period  of  incubution  is  about 
fourteen  days. 

Pathologic  Anatomy. — There  is  inflammation  of  one  or  both 
parotid  glands,  and  in  severe  epidemics  the  cellular  tissue  per- 
vading the  gland  is  involved.  The  catarrhal  inflammation 
begins  in  the  gland  ducts  and  rapidly  extends  to  the  gland 
proper.  There  are  congestion,  swelling,  and  an  infiltration  of 
serous  fluid,  the  latter  extending  to  the  adjacent  tissues.  The 
swelling  may  suddenly  reach  an  enormous  size  and  as  suddenly 
decline,  the  gland  returning  to  its  normal  condition,  or,  rarely, 
an  abscess  results,  with  partial  or  complete  destruction  of  the 
gland.  Occasionally  the  submaxillary  gland,  the  ovaries,  mam- 
maae,  and  testes  are  involved. 

Secondary  parotitis  occurs  as  a  complication  in  severe 
blood-poisoning,  as  in  pyemia,  typhoid,  or  typhus  fevers,  or 
diphtheria.  The  usual  termination  of  secondary  parotitis 
is  by  suppuration  and  destruction  of  gland-structure. 

Symptoms. — The  onset  is  rather  sudden,  attended  by  mal- 
aise, chill,  fever,  ioi°  to  103°  F.,  quick  pulse,  headache,  dry 
skin,  scanty  urine,  followed  within  a  day  or  two  by  pain  below 
and  in  front  of  the  ear,  with  stiffness  at  the  angles  of  the  jaw, 
swelling  of  the  parotid  and  other  salivary  glands,  pain  increased 
by  m.oving  the  jaws,  with  general  edema  of  the  affected  side 
of  the  face,  at  times  the  skin  being  reddened.  Salivation  is 
frequent  and  occasionally  deafness  occurs.  The  swelling  and 
other  glandular  symptoms  subside  about  the  seventh  to  the 
tenth  day,  to  be  followed  by  restoration  to  health  or,  what  is 
more  common,  the  involvement  of  the  opposite  gland. 

Complications. — Orchitis  is  the  most  frequent  complication, 
occurring  in  about  one-third  of  the  cases,  but  rarely  before 
the  age  of  puberty.  It  usually  occurs  about  the  eighth  day; 
and  one  or  both  testicles  may  be  involved. 

Vulo-vaginitis  sometimes  occurs  in  girls;  the  mammary 
glands  are  also  occasionally  involved.  Mastitis  has  also  been 
vSeen  in  boys. 

At  any  time  during  the  disease  metastasis  to  the  mammae, 
6 


82  DIPHTHERIA. 

ovaries,  or  testes  is  apt  to  occur,  when  the  symptoms  peculiar 
to  such  affections  will  be  added.  It  has  been  noted  that  a 
continuance  of  the  temperature  after  the  decline  of  the  parotid 
symptoms  has  begun  usually  is  significant  of  metastasis.  It 
is  claimed  that  the  involvement  of  other  organs  during  the 
course  of  mumps  is  not  an  example  of  metastasis,  but  is  a  true 
transfer  of  the  disease. 

Prognosis. — In  simple  cases  the  prognosis  is  favorable.  Metas- 
tasis to  other  organs  may  result  in  atrophy  or  impairment  of 
their  functions. 

Treatment. — Isolation  with  rest  and  liquid  diet  are  the  first 
indications.  If  the  temperature  is  high,  fever  mixtures  may  be 
employed.  Locally,  hot  fomentations  and  ointments  of  bella- 
donna, mercury,  and  guaiacol,  alone  or  combined,  are  of 
value  in  relieving  distress.  If  the  condition  tends  to  persist, 
blisters  should  be  applied  and  potassium  iodid  administered. 
Orchitis  will  require  hot  or  cold  local  applications  and  mercury 
and  belladonna  ointments  and  the  internal  use  of  tincture  of 
Pulsatilla,  nxiii  to  v  (0.2  to  0.3  c.c),  every  hour,  or  potassium 
iodid;  the  testicles  should  be  raised. 

DIPHTHERIA. 

Synonyms. — Membranous  croup;  true  croup;  malignant 
quinsy;  membranous  angina. 

Nomenclature. — The  term  diphtheria  is  applied  by  bacteri- 
ologists to  any  condition  (even  simple  sore  throat)  in  which  the 
Kleb-Loefffer  bacillus  is  found;  and  pseudodiphtheria,  or  diph- 
theroid, when  the  Klebs-Loeflfler  bacillus  is  not  present,  no 
matter  how  severe  the  other  signs  and  constitutional  disturb- 
ances may  be. 

Membranous  croup  or  true  croup  is  laryngeal  diphtheria ; 
Spasmodic  croup  or  false  croup,  or  catarrhal  croup,  is  a  form 
of  laryngitis  (see  page  516).  As  Greene  well  says:  ''Mem- 
branous croup  has  properly  been  shelved  by  modern  methods 
of  diagnosis  and  replaced  by  laryngeal  diphtheria,  which  in 
99  per  cent,  of  such  cases  is  the  proper  descriptive  term." 


DIPHTHERIA.  83 

Definition. — An  acute,  specific,  infectious  disease;  both 
epidemic  and  contagious,  beginning  by  an  affection  of  the 
throat,  characterized  by  a  local  exudation  and  glandular  en- 
largements; attended  with  fever,  constitutional  symptoms, 
great  prostration  of  the  vital  powers,  and  albuminuria,  and 
often  having  for  its  sequelae  various  paralyses. 

Causes. — A  specific  germ,  the  Klebs-Loeffler  bacillus.  The 
bacillus  in  its  growth  produces  a  potent  toxic  substance — a 
toxalbumin,  (whose  composition  is  unknown) — the  absorption  of 
which  produces  the  disease,  and  not  the  organism  itself.  The 
diphtheria  bacillus  is  associated  with  other  pathogenic  bacteria, 
such  as  streptococcus  pyogenes,  staphylococcus  aureus  and  albus, 
micrococcus  lance  olatus ,  and  bacillus  coli  communis.  It  is 
preeminently  a  disease  of  childhood.  It  is  apt-  to  recur  in 
those  who  have  once  been  affected.  All  conditions  of  bad 
hygiene  increase  its  virulence  and  diffusion,  although  the 
chief  cause  of  its  spread  is  contagion.  Nasal,  pharyngeal,  and 
laryngeal  catarrh  produce  a  soil  capable  of  promoting  the 
growth  of  the  bacillus  and  its  toxin.  The  poison  exists  in  the 
exudation  and  secretions  of  the  fauces  and  saliva,  and  floats 
in  the  atmosphere  at  a  considerable  distance  from  the  patient. 
The  virus  adheres  to  the  clothing,  the  bedding,  the  furniture, 
and  the  room  which  the  patient  occupied.  The  disease  is 
highly  contagious  and  may  be  contracted(i)  by  direct  con- 
tact with  an  infected  person;  (2)  by  contact  with  infected 
articles — fomites;  (3)  from  the  discharge  of  the  nose  and 
throat  of  persons  who  have  recently  had  the  disease;  (4)  from 
the  throats  of  ''diphtheria  carriers'' — persons  who  show  no 
signs  of  the  disease.  The  period  of  incubation  is  from  two  to 
seven  days. 

Pathologic  Anatomy. — The  diphtheritic  or  croupous  inflam- 
mation differs  from  the  catarrhal  form  in  that  the  exudation 
is  not  only  upon,  but  also  within,  the  substance  of  the  mucous 
membrane.  At  first  there  is  redness,  which  may  begin  in  any 
part  of  the  throat,  associated  with  swelling  and  an  increased 
secretion  of  viscid  mucus.  The  redness  spreads  over  the 
entire  mucous  surface,  when  the  exudation  makes  its  appear- 


84  DIPHTHERIA. 

ance,  at  first  giving  the  affected  mucotis  membrane  a  glazed 
appearance,  which  is  very  characteristic.  The  deposit  may 
commence  from  one  of  several  points,  such  as  one  tonsil,  the 
soft  palate,  or  the  back  of  the  fauces,  which,  however,  speedily 
extend  and  coalesce,  forming  extensive  patches,  or  cover 
uniformly  the  entire  surface.  The  patches  are  of  variable 
thickness,  which  is  increased  by  successive  layers  being  formed 
underneath. 

The  color  is  usually  gray,  white,  or  slightly  yellow,  but  may 
be  brownish  or  blackish,  the  consistence  ranging  from  "cream 
to  wash  leather."  On  removing  the  membrane,  which  is  ac- 
complished with  more  or  less  difficulty,  a  raw  bleeding  sur- 
face is  exposed,  and  at  times  an  ulcer,  which  is  speedily  cov- 
ered with  a  fresh  deposit.  If  the  exudation  separates  itself, 
it  is  either  not  renewed  at  all  or  only  in  thinner  films.  The 
exudation  or  membrane,  examined  by  the  microscope,  is  com- 
posed of  fibrin,  pus  corpuscles,  epithelial  granular  cells,  and 
the  Klebs-Loeffler  bacillus  and  other  pathogenic  bacteria.  It 
is  believed  to  be  a  product  of  coagulation  necrosis. 

Oertal  describes  the  local  changes  as  follows:  "The  poison 
first  induces  a  necrosis  of  the  cells  with  which  it  comes  in  con- 
tact; the  superficial  epithelium  thus  first  disappears.  The 
deeper  cells  become  similarly  affected,  and  a  zone  of  inflamma- 
tion forms  around  the  dead  cells;  the  membrane  thus  is  really 
a  mass  of  dead  cells  undergoing  hyaline  degeneration,  and 
mingled  with  fibrin,  and  it  presents  the  peculiar  laminated 
appearance  considered  characteristic.  The  neighboring  lym- 
phatic glands  become  much  enlarged." 

If  the  larynx,  trachea,  or  nasal  mucous  membranes  par- 
ticipate in  the  disease,  the  croupous  and  not  the  diphtheritic 
form  of  inflammation  occurs. 

The  lymphatic  glands  of  the  neck,  whose  vessels  originate 
in  the  faucial  tissues,  are  enlarged  and  inflamed  and  contain 
large  numbers  of  bacteria,  probably  originating  as  the  result 
of  decomposition. 

The  muscular  tissue  of  the  heart  becomes  soft,  is  easily  torn, 
and  its  fibrilfe  are  far  advanced  in  granular  degeneration.     Ul- 


DIPHTHERIA.  85 

cerative  endocarditis  has  been  frequently  observed.  The 
kidneys  undergo  a  granular  degeneration  in  severe  attacks. 
The   blood   undergoes    alteration,    becoming   black   and   fluid. 

Symptoms. — As  is  commonly  seen  in  contagious  diseases, 
the  symptoms  vary  in  intensity  in  different  cases,  the  promi- 
nent symptoms  being  often  disproportionate  to  the  gravity  of 
the  attack.  The  invasion  may  be  mild,  with  rigors  succeeded 
by  moderate  fever,  headache,  languor,  loss  of  appetite,  stiff- 
ness of  the  neck,  tenderness  about  the  angles  of  the  jaw,  or 
slight  soreness  of  the  throat.  In  other  cases  the  invasion  is 
more  abrupt  and  severe,  with  chilliness  followed  by  great 
febrile  reaction,  103°  to  105°  F.,  pain  in  the  ear,  aching  in  the 
limbs,  loss  of  strength,  painful  deglutition,  and  swelling  of  the 
neck,  compelling  the  patient  to  take  to  bed  from  the  onset. 
The  appetite  is  poor,  the  tongue  slightly  coated,  sometimes 
more  or  less  exudation  appearing  upon  it,  the  bowels  either 
regular  or  slightly  relaxed.  The  pulse  at  first  full  and  strong, 
soon  becomes  either  rapid  or  slow,  but  compressible.  The 
urine  is  scanty,  high-colored,  and  contains  albumin.  Prostra- 
tion and  weariness  are  present  to  a  marked  degree. 

The  local  symptoms  in  the  majority  of  cases  are  associated 
with  the  throat.  The  patient  often  complains  of  a  frequent 
and  persistent  desire  to  hawk,  in  order  to  clear  the  throat.  On 
inspection,  the  fauces  are  seen  red  and  swollen  and  more  or 
less  covered  with  a  film  of  diphtheritic  exudation,  giving  a 
glazed  appearance,  soon  followed  by  the  dirty- white  membrane; 
sometimes  the  tonsils  and  uvula  are  greatly  swollen  and  spotted 
with  exudation.  Removal  of  the  false  membrane  exposes  to  view 
a  raw  bleeding  surface  over  which  a  new  membrane  promptly 
forms.  In  severe  cases  more  or  less  ulceration  or  sloughing 
may  be  observed.  Not  infrequently  fragments  of  exudation, 
the  false  membrane,  are  expectorated,  with  particles  of  the  ul- 
cerated tissues,  having  an  offensive  odor,  which  is  transmitted 
to  the  breath.  The  lymphatic  glands  of  the  neck  are  enlarged 
and  tender,  and  in  severe  cases  the  tissues  of  the  neck  are 
greatly  tumefied. 

Extension  to  the  nasal  cavities  causes  a  sanious  and  offensive 


86  DIPHTHERIA. 

discharge  from  the  nose,  with  attacks  of  epistaxis.  Constitutional 
reaction  is  marked.  Enlargement  of  the  deep  faucial  glands  at 
the  angle  of  the  jaw  is  characteristic  of  this  form  of  the  disease. 

Extension  to  the  larynx  is  indicated  by  hoarseness  or  com- 
plete loss  of  voice,  croupy  cough  and  obstructive  dyspnea, 
which  often  becomes  urgent,  the  breathing  being  noisy  and 
stridulous  and  subject  to  paroxysmal  exacerbations.  If  the, 
inflammation  extends  to  the  bronchi,  the  breathing  becomes 
still  more  embarrassed.  This  variety  runs  a  rapid  course  and 
often  terminates  in  death  by  suffocation. 

Duration.— The  disease  lasts  from  two  to  fourteen  days,  the 
average  being  about  nine  days,  although  complications  and 
sequels  may  prolong  its  course.      Relapses  are  not  uncommon. 

Complications  and  Sequels. — Eruptions  on  the  skin,  such  as 
erythema,  urticaria,  and  purpura  may  occur  in  the  course  of 
the  disease  and  while  not  of  serious  importance  may  lead  to 
errors  in  diagnosis.  The  most  common  complication  is  neph- 
ritis. Albuminuria  is  present  in  nearly  all  severe  cases  of 
diphtheria,  but  when  it  is  associated  with  blood  casts,  epithelial 
casts,  and  scanty  urine,  the  presence  of  parenchymatous  neph- 
ritis is  indicated.  Capillary  bronchitis,  bronchopneumonia, 
endocarditis,  arthritis,  meningitis,  and  otitis  media  also  occur 
as  complications. 

After  a  severe  attack  patients  often  remain  anemic  and  ca- 
chectic for  an  indefinite  period.  Paralysis,  due  to  toxic  neuritis, 
is  a  common  sequel  (lo  to  20  per  cent.)  following  the  mild  as 
well  as  the  severe  attacks.  It  may  appear  at  the  end  of  the 
first  week,  but  usually  presents  itself  after  convalescence  has 
been  established.  It  most  frequently  affects  the  pharyngeal 
muscles  and  palate  seriously  interfering  with  deglutition  and  im- 
pairing the  voice.  Anesthesia  of  the  pharyngeal  mucous  mem- 
brane occurs  coincidentally.  The  eye  muscles  are  affected 
next  in  frequency.  Facial  paralysis  and  palsy  of  the  extremities 
may  also  occur.  Sensation  and  reflexes  are  diminished  in  the 
paralyzed  parts.  Neuritis  of  the  cardiac  nerves  is  not  in- 
frequent, resulting  in  brachycardia,  tachycardia,  and  even 
sudden  cessation  of  the  heart's  action,  and  death. .   The  pul- 


DIPHTHERIA.  87 

sations  have  been  known  to  fall  to  20  per   minute.      Multiple 
neuritis  rarely  occurs  as  a  sequel. 

Diagnosis. — The  onset,  course,  throat  symptoms,  prostra- 
tion, and  the  results  of  microscopic  examination  of  cultures 
taken  from  the  throat  are  the  characteristics  of  this  disease. 

Intense  follicular  tonsillitis  due  to  streptococcic  infection 
may  be  mistaken  for  diphtheria.  This  exudate  usually  shows 
no  tendency  to  spread  and  is  in  most  cases  limited  to  one  tonsil ; 
dropping  out  at  the  end  of  the  second  or  third  day,  and  leaving 
a  clean-cut  ulcer  which  heals  rapidly.  Microscopic  examination 
is  diagnostic. 

Scarlet  fever  may  be  confused  with  diphtheria,  but  the  charac- 
teristic eruption,  strawberry  tongue,  rapid  pulse,  and  the  ab- 
sence of  the  diphtheria  bacillus  will  serve  to  distinguish  them. 
They  may  exist  coincidentally  in  the  same  patient. 

Many  cities  in  the  United  States  now  offer,  through  their 
health  bureaus,  to  make  bacteriological  examinations  for  phy- 
sicians in  all  cases  of  possible  diphtheria. 
Outfits  are  left  at  stations.  They  consist 
of  a  box  containing  a  tube  of  blood-serum 
and  another  containing  a  sterilized  swab. 
The  following  directions  are  issued  by  the 
Philadelphia  Board  of  Health: 

"  Inoculations  should  be  made  by  rubbing 

the  cotton  swab  attached  to  the  end  of  the      ^ig     x6. Diphtheria 

wire   contained  in  the  test-tube  gently,  but   bacillus   (bacillus   diph- 

°  -''  theri£e)oi    LrOeiner. 

freely,  against  any  visible  exudate,  and  then    {From  Greene's  Medical 

DtdSfiosts.) 

drawing  it  over  the  surface  of  the  culture - 
medium  without  breaking  the  surface  of  the  latter.  The  swab 
should  then  be  replaced  in  the  tube  from  which  it  was  taken, 
and  both  tubes  be  replugged  and  put  back  into  the  box.  Re- 
turn the  box  to  the  station  from,  which  it  was  obtained  as 
soon  as  possible  or  bring  it  directly  to  the  laboratory.  The 
tubes  will  be  collected  every  afternoon,  examined  the  following 
morning,  and  reports  will  be  mailed  by  one  o'clock  p.  m.  The 
attending  physician  can  obtain  information,  however,  by  tele- 
phoning directly  to  the  laboratory  after  that  hour." 


88  DIPHTHERIA. 

Prognosis. — Always  grave,  but  more  so  in  children  than  in 
adults.  Its  gravity,  in  the  majority  of  cases,  is  proportionate 
to  the  local  symptoms.  -  The  average  mortality  is  now  about  lo 
per  cent. 

Favorable  indications  are  moderate  fever,  strength  slightly 
impaired,   a  good  constitution,   and  moderate  exudation. 

Unfavorable  indications  are  high  fever,  great  depression, 
spreading  exudation,  great  swelling  of  the  cervical  glands, 
large  amounts  of  albumin,  extension  to  larynx  and  nasal 
mucous  membranes,  hemorrhages  from  the  fauces  and  nose,  and 
an  epidemic  character. 

Treatment. — Antitoxin  serum  is  indicated  in  all  cases.  It 
should  be  administered  at  once  if  there  is  any  likelihood  of  the 
disease  being  diphtheria;  do  not  wait  for  the  bacteriological 
diagnosis.  It  may  also  be  employed  as  a  prophylactic  measure 
in  those  exposed  to  the  contagion.  The  injections  should  be 
made  where  the  skin  is  loose  and  at  points  that  will  not  inter- 
fere with  the  patient's  comfort.  The  dose  is  estimated  in  anti- 
toxic units  and  not  by  the  unit  of  the  serum.  The  immuniz- 
ing dose  is  from  500  to  1000  units  (according  to  the  age  of  the 
person  to  be  protected) ;  the  curative  dose  is  from  3000  to  5000 
units. 

"  In  favorable  cases,  after  twenty-four  hours  have  passed, 
the  temperature  will  not  have  risen;  the  pulse  will  be  slower; 
the  membrane  will  not  have  spread;  the  mucous  membrane  at 
the  edge  of  the  exudation  will  be  bright  red  in  color.  There 
will  be  a  feeling  of  diminished  discomfort  and  revival  of  spirits. 
These  are  favorable  signs,  and  a  second  dose  need  not  be  admin- 
istered. A  second  dose  is  administered  after  twenty -four  hours 
if  the  temperature  has  risen,  if  the  membrane  is  spreading,  and 
if  the  general  condition  of  the  patient  is  not  so  good  as  at  the 
previous  injection.  As  might  be  expected,  improvement  is 
more  rapid  in  mild  cases"  (Tyson). 

It  must  be  remembered  that  there  is  no  way  of  estimating 
the  "dosage"  of  antitoxin  required;  hence  it  should  be  admin- 
istered till  the  characteristic  effect  is  produced — shriveling  of 
the  membrane,  diminution  of  the  nasal  discharge  and  of  fetid 


DIPHTHERIA.  89 

odor,  and  a  generally  improved  condition  of  the  patient.  In 
addition  to  the  antitoxin  treatment  supportive  measures  are 
indicated  to  combat  the  profound  prostration.  The  patient 
should  be  isolated  and  means  taken  to  prevent  spreading  of 
the  disease.  Rest  in  bed  with  the  employment  of  a  diet  com- 
posed of  milk,  eggs,  broths,  oysters,  etc.,  every  two  or  three 
hours  is  indispensable.  If  deglutition  is  painful  or  difficult, 
resort  must  be  had  to  nutritive  enemas,  such  as  the  following: 

I^.     Milk gj  30.  CO. 

Spts.  frumenti 3iv  15.  c.c. 

Egg One. 

M.  S. — Add  a  small  quantity  of  salt,  mix  thoroughly,  and 
use  as  directed. 

The  room  in  which  the  patient  is  confined  should  be  well 
ventilated  and  its  temperature  maintained  at  an  average  of 
70°  F.  The  atmosphere  should  be  rendered  warm  and  moist 
.by  generating  steam  from  an  ordinary  hot-water  kettle  or  by 
slaking  lime  in  the  sick-room.  In  the  laryngeal  form  direct 
inhalations  of  hot-water  vapor  are  indicated.  Ice-pellets 
placed  in  the  mouth  afford  great  relief  during  these  inhalations. 
Sponges  dipped  in  hot  water  and  applied  to  the  angles  of  the 
jaw  are  also  beneficial.  To  prevent  dissemination  of  the  poison 
by  the  exhaled  air.  Dr.  J.  Lewis  Smith  advises  the  following: 
Add  four  ounces  of  the  following  solution  to  one  quart  of  water 
and  allow  this  to  simmer  constantly,  near  the  patient,  in  a 
broad-surfaced  tin  or  zinc  wash-basin:  I^.  Olei  eucalypt.,. 
acidi  carbolici,  aa  fBj  (30  c.c);  spirit,  terebinthinse,  foviij 
(240  c.c).  M.  The  vapor  is  strong,  penetrating,  and  pro- 
phylactic, but  not  unpleasant.  In  hot  weather,  or  when  a  fire 
is  not  convenient,  saturate  cloths  a  foot  square  with  the  same 
solution  and  place  them  on  paper  on  the  bed  of  the  patient. 

The  medical  treatment  is  general  and  local.  Internally, 
stimulants  should  be  used  boldly  from  the  onset;  it  is  a  mis- 
take to  wait  for  signs  of  debility  before  using  alcohol  in  this 
disease.  Other  stimulants,  such  as  strychnin,  quinin,  digi- 
talis, nitroglycerin,  and  caffein  should  also  be  employed.     Tine- 


90  DIPHTHERIA. 

ture  of  the  chlorid  of  iron  and  bichlorid  of  mercury  are  used 
frequently  in  the  following  combination: 

I^.      Hydrargyri  chloridi  cor- 

rosivi gr.  1/48  .0015     gm. 

Tinct.  ferri  chloridi tt^v  to  x  .  3  to  .  6  c.c. 

Glycerini vr[x.  .6  c.c. 

Aquae f  5  j  4  .  c.c. 

M.  S. — Every  hour  or  two,  well  diluted. 

The  addition  of  tincture  of  belladonna,  nxi  to  v  (0.06  to  0.3 
c.c),  to  each  dose  increases  its  efficiency. 

A  combination  of  iron  and  potassium  chlorate  in  full  doses, 
frequently  repeated,  seems  to  modify  the  course  of  the  malady 
and  has  the  additional  advantage  of  acting  locally  as  it  is 
swallowed. 

The  following  formula  is  frequently  used: 

I^.     Tinct.  ferri  chlorid vriv  to  x  .  3  to  .  6  c.c. 

Potassii  chlorat gr  iij  to  v  .  2  to  .  3  gm. 

Glycerini f  5ss  2  .  c.c. 

Syr.  zingib q.  s.  ad  f  5 j  to  ij  ad  4 .  to  8  .     c.c. 

M.  S. — In   water    every   three   hours,  for  a   child  of  two  or 
three  years. 

Calomel  in  small  doses  (gr.  1/6),  combined  with  sodium  bicar- 
bonate every  hour  until  spawn-like  stools  are  produced,  is 
beneficial,  especially  in  cases  showing  a  tendency  to  spread  to- 
ward the  larynx.  Indeed,  a  tolerance  to  calomel  seems  to 
exist  in  laryngeal  diphtheria. 

In  all  cases  the  bowels  should  be  kept  regular  by  the  use  of 
laxatives  and  the  urine  should  be  carefully  watched  through- 
out the  entire  course  of  the  disease;  diminution  in  the  amount 
with  considerable  albumin  is  of  grave  significance. 

Locally,  measures  should  be  employed  tending  toward  the 
prevention  of  the  spread  of  the  infection.  It  is  impossible  to 
dissolve  the  false  membrane  in  the  throat  by  applications. 
Peroxid  of  hydrogen  (50  per  cent.)  or  Dobell's  solution,  used 
in  a  spray  or  on  a  cotton  swab  or  sponge,  should  be  freely  em- 


DIPHTHERIA.  9 1 

ployed  every  hour  to  keep  the  mouth  and  pharynx  as  aseptic 
as  possible.  Bichlorid  of  mercury  (i  to  4000),  carbolic  acid 
(3  per  cent,  solution  in  ecfual  parts  of  glycerin  and  water), 
salicylic  acid  (i  to  300),  thymol  (i  to  2000),  lactic  acid  (30  gr. 
to  the  ounce),  trypsin  (30  gr.  to  the  ounce),  and  papoid  may 
also  be  used  as  local  applications.  The  addition  of  tartaric 
acid  to  bichlorid  of  mercury  increases  its  germicide  properties. 
In  a  I  to  500  solution  the  proportions  are  as  follows:  bichlorid 
of  mercury,  gr.  3.75  (0.25  gm.),  tartaric  acid,  gr.  19.25  (1.2  5gm.), 
water,  4  f§  (120  c.c).  The  following  formulas  are  of  value 
for  local  use: 

I^.      Acidi  carbolici n^xx  i .  3  c.c. 

Tinct.  ferri  chlorid f  5iv  1 5  .     c.c. 

Glycerini f  § j  30.     c.c. 

Aq.  destil f  §j  30  .     c.c. 

M.  S. — Apply  locally  by  means  of  a  swab  every  three  hoiirs. 

I^.     Potass,  chlorat oiv  15  .  gm. 

Acid,  carbol gr.  ij  to  iv         .  13  to  .  26  gm. 

Tinct.  myrrh fSj  30.  c.c. 

Inf.  cinchonae f  §ij  60.  c.c. 

M.  S. — Use  as  a  gargle  or  apply  to  throat  with  a  cotton 
swab, 

I^.     Menthol 10. o  gm. 

Toluol q.  s.  ad.  36.0  c.c. 

M.     Et  adde. 

Ferri  sesquioxid • 4  .       c.c. 

Alcohol  absolut 60 .      c.c. 

M.  S. — Loeffler's  Solution.     Apply  to  throat  by  means  of 
cotton  swab. 

Avoid  struggling  with  children  in  an  effort  to  forcibly  spray 
or  gargle  the  throat  and  nose;  instead,  add  glycerin  to  their 
internal  medicine,  and  allow  no  liquids  for  some  time  after  its 
administration. 

In  laryngeal  diphtheria,  the  general  treatment,  especially 
the  mercurial  medication,  should  be  the  same.  The  patient 
should  inhale  the  vapor  of  slaking  lime  and  lime-water  (3  parts) 


92  DIPHTHERIA. 

and  glycerin  (i  part).  Emetics  are  often  prescribed  to  pro- 
mote the  expulsion  of  the  false  membrane;  for  this  purpose 
wine  of  ipecac  may  be  used.  Wlfen  suffocation  is  threatened 
from  the  laryngeal  obstruction,  intubation  or  tracheotomy 
should  be  performed   mmediately. 

Nasal  diphtheria  requires  the  same  general  treatment  as  the 
faucial  variety,  with  additions  of  thorough  cleansing  of  the 
nasal  cavities  every  two  hours  with  peroxid  of  hydrogen,  car- 
bolic acid,  boric  acid  solution,  Dobell's  solution,  potassium 
chlorate,  or  the  following: 

I^,      Sodii  sulphit 5iij  12  .  gm. 

Glycerini f  3ij  8 .  c.c. 

Aquae foiv  120.  c.c. 

M.  S. — Use  locally  as  directed. 

The  nozzle  of  the  syringe  must  be  passed  in  horizontally, 
not  vertically;  or  the  fluid  will  return  through  the  same  nostril. 

During  convalescence  in  all  forms,  stimulation  should  be 
continued  to  prevent  sudden  heart-failure.  Iron,  quinin, 
strychnin,  cod-liver  oil,  arsenic,  etc.,  will  be  necessary  to  com- 
bat the  attendant  anemia  and  restore  strength.  Paralysis 
will  necessitate  massage  and  electricity  in  addition. 

Prophylaxis. — As  in  other  contagious  diseases  the  patient 
should  be  isolated  in  a  room  stripped  of  all  unnecessary  furni- 
ture and  draperies.  Everything  used  by  the  patient  or  with 
which  he  comes  in  contact  should  be  reserved  for  him  alone. 
Instruments,  tongue  depressors,  spoons,  etc.,  should  be  boiled 
or  kept  immersed  in  carbolic  acid  solution.  Bed  linen,  cloth- 
ing, etc.,  should  be  sterlized  by  boiling  or  by  exposure  to  super- 
heated steam.  Formaldehyd  gas  is  employed  for  disinfec- 
tion of  the  room  (after  the  patient's  removal)  and  its  contents. 
All  attendants  should  wear  a  gown  of  washable  material  on 
entering  the  sick-room,  discarding  the  same  on  leaving  it.  The 
hands  should  be  washed  and  immersed  in  an  antiseptic  solution 
before  leaving  the  room.  After  convalescence  is  established 
the  patient  should  be  washed  with  soap  and  hot  water  and 
then  with  alcohol  (50  per  cent.),  carbolic  acid  solution  (2  per 


GLANDERS   AND    FARCY.  93 

cent.),  or  bichlorid  of  mercury  (i  to  2000  solution)  for  three 
days  in  succession.  The  hair  should  be  similarly  treated  or,  in 
some  cases,  cut  off. 

GLANDERS  AND  FARCY. 

Definition.- — An  infectious  disease  of  the  horse,  communi- 
cable to  man  and  some  domestic  animals,  but  nOt  to  cattle; 
characterized  by  nodular  growths  in  the  nose,  when  it  is  known 
as  glanders,  and  under  the  skin,  when  it  is  called  farcy. 

Cause. — It  is  due  to  a  specific  bacillus — Bacillus  mallei. 
The  organism  resembles  the  tubercle  bacillus,  though  somewhat 
shorter  and  thicker.  The  disease  is  communicated  by  the  dis- 
charge from  an  infected  animal  to  an  abraded  skin  or  mucous 
surface;  it  may  also  be  caused  by  the  inhalation  of  the  dried 
mucus.     Contagious.     Incubation  from  three  to  five  days. 

Pathologic  Anatomy. — Nodules,  consisting  of  aggregations 
of  round  cells  of  lymphoid  or  polymorphonuclear  type,  which 
have  a  strong  tendency  to  suppurative  or  necrotic  softening. 
'In  man  the  nodules  are  usually  small  and  consist  of  lymphoid 
and  endothelial  cells,  within  and  between  which  the  bacilli 
are  to  be  found.  The  floor  arid  edges  of  the  ulcers  (softened 
nodules)  are  irregular  and  yellowish,  discharging  more  or  less 
purulent  matter.  The  nodules  develop  particularly  in  the 
nares,  the  skin,  and  muscles;  but  internal  organs  (as  lungs,  liver, 
spleen,  kidneys,  stomach,  nervous  system,  and  bones)  may  be 
invaded.  The  lymphatic  glands  of  the  neck  and  elsewhere 
enlarge  and  may  suppurate. 

Symptoms. — There  is  an  acute  and  a  chronic  form  of  glanders. 

Acute  Glanders. — Redness  and  swelling  of  the  nasal  mucous 
membrane  with  burning  and  dryness,  followed  by  the  develop- 
ment of,  the  nodules,  which  rapidly  break  down  and  discharge 
a  fetid  hemorrhagic  or  muco-pus.  Soon  there  develop  head- 
ache,' painful  deglutition,  cough,  fever,  prostration,  and  ty- 
phoid symptoms,  terminating  eventually  in  death. 

Chronic  glanders  is  rare  and  is  difficult  to  recognize;  it  is 
generally  mistaken  for  a  chronic  coryza. 


94  FOOT  AND   MOUTH   DISEASE. 

Acute  farcy,  or  glanders  of  the  skin,  consists  of  nodular  swell- 
ings with  subsequent  ulcers  and  discharge  of  a  fetid  hemor- 
rhagic pus  on  the  skin.  Papules,  becoming  pustules,  followed 
by  ulceration,  occur  in  the  neighborhood  of  the  nodules.  The 
lymphatic  glands  and  vessels  are  involved,  and  the  glands  may 
suppurate,  being  then  called  "farcy  buds;"  the  nose  is  not 
affected.  Prostration  and  typhoid  symptoms  rapidly  develop. 
The  bacilli  have  been  found  in  the  urine,  both  in  man  and 
animals. 

In  chronic  farcy,  the  development,  course,  and  symptoms 
are  all  of  less  severity. 

Diagnosis. — The  certainty  of  diagnosis  is  made  possible 
only  by  making  cultures.  Inoculation  with  mallein  may  be 
tried;  it  causes  a  rise  of  temperature  in  affected  cases. 

Prognosis. — Acute  variety,  fatal.  Chronic  variety,  if  early 
diagnosed,   about   50  per  cent,   may  recover. 

Treatment. — Palliative  and  surgical  means  may  be  tfied  for 
the  lesions.  Sometimes  inunctions  of  mercury,  and  internal 
administration  of  potassium  iodid,  are  of  service.  Mallein  has 
been  tried  in  animals  with  variable  success. 

FOOT  AND  MOUTH  DISEASE. 

Synonyms. — Epidemic  stomatitis;  aphthous  fever. 

Definition. — An  acute  infectious  disease  of  the  lower  animals, 
communicable  to  man  and  characterized  principally  by  an 
eruption  of  vesicles  and  ulcer  on  the  mucous  membrane  of 
the  mouth  and  on  the  skin  between  the  toes. 

Etiology. — -It  is  supposed  to  be  caused  by  a  microorganism 
not  yet  determined.  It  is  chiefly  contracted  by  milkers  and 
those  who  work  with  diseased  cattle ;  but  milk,  butter,  and  cheese 
are  capable  of  communicating  the  disease  to  man. 

Symptoms. — The  incubation  period  varies  from  three  to 
five  days  and  the  disease  is  ushered  in  with  slight  constitutional 
reaction.  The  characteristic  vesicles  then  appear,  attended 
with  swelling  and  sensations  of  heat  and  burning.  Salivation 
is  profuse.  The  eruption  appears  between  the  toes  and  fingers 
at  the  same  time,   and  may  extend  over  the  entire  body. 


CHOLERA.  95 

Prognosis. — In  man  recovery  is  the  rule,  except  in  the  case 
of  very  young  and  weak  children  that  are  constantly  exposed 
to  the  affection. 

Treatment. — This  is  largely  prophylactic.  Cleanliness  of 
both  man  and  beast  will  accomplish  a  great  deal  in  preventing 
and  curing  the  disease;  the  milk  should  be  boiled.  Mild  anti- 
septic mouth  washes  containing  borax,  potassium  chlorate, 
etc.,  should  be  employed. 

CHOLERA. 

Synonyms. — Asiatic  cholera;  epidemic  cholera;  malignant 
cholera. 

Definition. — An  acute,  specific,  infectious  disease  occurring 
usually  in  epidemics,  but  may  be  endemic  in  certain  localities, 
as  in  parts  of  India;  characterized  by  violent  vomiting,  and 
purging  of  a  peculiar,  rice-water-like  fluid,  severe  muscular 
cramps,  and  a  condition  of  prostration  followed  by  collapse 
and  death,  or  of  reaction  from  collapse  with  the  subsequent 
development  of  a  typhoid  state  (cholera  typhoid). 

Causes. — A  specific  poison,  the  "comma  bacillus"  or  "spi- 
rocheta  cholerae"  of  Koch,  which  is  found  in  great  numbers 
in  the  discharges.  Cholera  is  not  highly  contagious  in  the 
usual  acceptation  of  that  word,  but  it  is  unquestionably 
infectious. 

The  evidence  seems  conclusive  that  the  cholera  stools  are  the 
main,  if  not  the  only,  channel  of  infection  and  that  the  great 
cause  of  the  propagation  of  cholera  is  the  contamination,  with 
the  chlorea  stools,  of  the  water  used  for  drinking  purposes. 
Contaminated  food  and  milk  may  also  be  the  vehicle  by  which 
it  spreads.  Flies  may  act  as  carriers  of  the  contagion.  It  is 
claimed  that  the  bacillus  is  inert  in  the  intestinal  canal  unless 
the  individual  is  in  the  "receptive  state" — that  is,  the  subject 
of  intestinal  catarrh,  such  as  results  from  eating  unripe  fruit, 
and  indigestible  food,  and  beer  and  spirit  drinking.  It  is  also 
determined  that  the  bacilli  are  destroyed  by  acids,  and  that  if 
the  stomach  be  normal,   cholera  will  not  result.      "  With  pure 


96  CHOLERA.. 

water,  pure  air,  pure  soil,   and  pure  habits,   cholera  need  not 
be  feared"    (Hart). 

Little,  if  any,  danger  exists  from  being  in  the  presence  of  the 
affected,  although  the  emanations  from  the  cholera  excreta 
in  the  atmosphere  may  generate  the  disease  if  swallowed  or 
inhaled.  The  dead  bodies  of  cholera  subjects  possess  some 
infective  property,  "the  bacteria  of  decomposition"  probably 
destroying  the  cholera  germs.  The  disease  follows  the  lines 
of  human  travel;  caravans  and  ships  are  prime  carriers  of  it: 
One  attack  does  not  afford  protection  against  another. 

Pettenkofer  maintains  that  the  cholera  germs  develop  in 
the  soil-water  of  the  earth  during  the  warm  months  and  that 
they  rise  into  the  atmosphere  as  a  miasm;  favorable  conditions 
being  low-ground  water,  porosity  and  moisture  of  soil,  and 
contamination  with  organic  matter,  especially  sewage. 

The  disease  is  usually  observed  during  the  summer  months, 
and  exempts  no  age.  Debility,  ill-health,  gastrointestinal 
catarrh,  fright,  anxiety,  fatigue,  intemperance,  and  uncleanli- 
ness  are  predisposing  causes.  The  incubation  period  is  from 
three  to  five  days. 

Pathologic  Anatomy. — The  morbid  appearances  in  the  ma- 
jority of  cases  of  death  from  cholera  may  be  thus  summarized. 
The  temperature  generally  rises  after  death,  the  body  remaining 
warm  for  a  considerable  time.  Rigor  mortis  rapidly  ensues, 
the  muscular  contractions  being  often  so  powerful  as  to  displace 
and  distort  the  limbs.  The  skin  is  mottled  and  the  body 
greatly  shrunken.  "  The  appearances  of  such  a  body  are 
those  of  a  wasted  cadaver  long  immersed  in  the  pickling  vats  of 
the  dissecting-room."  The  blood  is  dark  in  color,  and  thick. 
The  arteries  are  empty  of  blood;  the  veins,  on  the  other  hand, 
are  distended.  The  organs  are,  as  a  rule,  pale  and  shrunken. 
The  stomach  and  intestinal  mucous  membranes  are  congested 
and  present  evidence  of  extravasation  and  ecchymoses,  or 
are  bleached  and  pale.  The  stomach  and  intestines  usually 
contain  a  quantity  of  whey-like  material,  having  an  alkaline 
reaction,  as  well  as  quantities  of  cast-off  epithelium  and  the 
bacillus.      It  is  thought  by  many  that  the  stripping-off  of  the 


CHOLERA.  97 

epithelmm  is  a  post-mortem  phenomenon.  The  Peyer's, 
solitary,  and  Brunner's  glands  are  usually  enlarged  and  promi- 
nent, and  occasionally  evidences  of  ulceration  are  apparent 
in  the  solitaiy  glands,  and  sections  placed  under  the  microscope 
show  the  ' '  comma  bacillus. ' '  The  villi  of  the  mucous  membrane, 
as  well  as  the  epithelium  of  the  small  intestines,  are  stripped 
off,  leaving  the  basement  membrane^for  the  most  part,  exposed. 
The  liver  is  more  or  less  advanced  in  fatty  degeneration,  present- 
ing a  somewhat  mottled,  yellowish  discoloration.  The  spleen  is 
usually  small.  The  kidneys  are  congested,  the  epithelium  of 
the  tubules  granular  and  detached  from  the  basement  mem- 
brane, blocking  up  the  tubes.  Bartholow  observed,  in  all  of 
his  autopsies,  "  considerable  hyperemia  and  dilatation  of  the 
vessels  of  the  medulla  oblongata.  The  constancy  of  this 
lesion  would  seem  to  indicate  a  relationship  between  conges- 
tion of  the  medulla  and  the  cramps."  The  symptoms  are  in 
all  probability  induced  by  the  absorption  of  poisons  generated 
by  the  microorganisms  in  the  intestinal  tract. 

Symptoms. — In  accordance  with  the  law  of  epidemic  infecti- 
ous diseases,  the  onset,  course,  and  character  of  the  symptoms 
vary  in  different  cases  and  at  different  periods  in  the  same 
epidemic. 

The  disease  may  either  set  in  suddenly  in  a  patient  previously 
in  good  health,  or  it  may  follow  an  attack  of  rather  severe  and 
persistent  diarrhea,  with  pain,  nausea,  vomiting,  and  de- 
pression. Such  cases  are  termed  cholerine,  the  stools  of  which 
are  infectious. 

In  a  typical  case  there  are  three  stages:  first,  diarrhea; 
second,   collapse   (also  called  algid  stage) ;  third,   reaction. 

First  Stage.  This  stage  begins  with  chilliness,  excessive 
thirst,  coated  tongue,  unpleasant  taste  in  the  mouth,  slight 
abdominal  pain,  and  three  or  four  copious,  watery,  yet  fecal 
stools  during  the  day,  and  a  decided  feeling  of  weakness,  the 
stools  rapidly  becoming  whey-like,  easily  voided,  but  with 
force,  and  only  slight  pain.  Occasionally  an  erythematous 
rash  is  present. 

Second    Stage.     The  stools  rapidly  increase  in  number,   are 

7 


98  CHOLERA. 

voided  with  a  rushing  force,  and  consist  of  many  quarts  of 
grayish  or  whitish  rice-water-like  fluid,  accompanied  with 
forcible  vomiting,  first  of  the  contents  of  the  stomach,  mixed 
with  more  or  less  bilious  matter,  afterward  of  the  peculiar 
rice-water-like  material;  thirst  becomes  most  intense,  increas- 
ing or  diminishing  with  the  variations  in  the  number  of  the 
stools  and  vomiting;  severe  muscular  cramps  soon  follow, 
most  severe  in  the  calves,  although  occurring  in  all  parts  of 
the  body.  The  stools,-  vomiting  and  cramps  continue.  The 
appearance  of  the  patient  becomes  frightful;  the  eyes  are 
sunken  and  surrounded  by  blackened  rings,  the  nose  pinched 
and  pointed,  the  cheeks  hollow,  and  the  lips  blue  (facies  chol- 
erica) ;  the  surface  cold  and  moistened  with  a  sticky  perspira- 
tion; the  skin  of  the  hands  and  fingers  has  the  sodden  ap- 
pearance of  the  "washerwoman  who  has  washed  all  day" 
and,  if  picked  up  in  folds,  the  fold  but  slowly  disappears.  The 
temperature  rapidly  falls,  the  pulse  becomes  small  and  com- 
pressible, barely  perceptible  at  the  wrist,  and  the  heart-beats  are 
scarcely  recognizable.  The  voice  is  weak,  husky,  and  sepul- 
chral (vox  cholerica),  the  tongue  is  like  ice,  the  breath  is  cold 
and  icy,  the  urine  markedly  diminished  and  albuminous.  The 
mind  is  clear,  but  most  patients  are  apathetic  and  indifferent 
to  their  danger.  This,  the  algid  state  of  cholera,  or  cholera 
asphyxia,  usually  terminates  in  death  in  from  three  to  twelve, 
twenty-four,  or  forty-eight  hours,  but  reaction  may  be 
established. 

Third  Stage.  The  temperature  of  the  body  rises,  the  pulse 
gradually  becomes  fuller  and  stronger,  the  countenance  be- 
comes brighter,  the  stools  less  frequent  and  more  fecal,  the 
vomiting  decreases,  the  thirst  lessens,  the  urine  increases  in 
amount,  but  continues  albuminous,  the  patient  entering  a 
slow  convalescence,  or  typhoid  symptoms  develop,  the  so- 
called  cholera  typhoid,  which  prolongs  the  recovery  for 
several  weeks.  Cases  are  sometimes  observed  in  which  collapse 
and  death  occur  without  any  intestinal  discharges.  These  are 
termed  cholera  sicca. 

Convalescence    is   often   prolonged   and   complicated   by   the 


CHOLER.^.  99 

development  of  severe  bed-sores,  boils,  bronchitis,  pneumonia 
or  parotitis. 

The  prodromal  stage  lasts  from  a  few  hours  to  a  week;  the 
stage  of  collapse  from  a  few  hours  to  twelve  or  twenty-four 
hours;  the  stage  of  reaction  a  few  hours,  and  the  stage  of  con- 
valescence several  weeks. 

Complications  and  Sequels. — Suppuration  of  the  parotid 
gland,  nephritis,  painful  tetanic  contractions  of  the  flexor 
muscles  of  the  limbs,  pneumonia,  pleurisy,  corneal  ulcers, 
abscesses,  ulcers,  or  gangrene  of  the  extermities,  profuse 
sweats,  and  various  cutaneous  eruptions. 

Diagnosis. — The  epidemic  character,  rapid  spreading,  and 
great  mortality  of  the  afifection  prevents  its  being  mistaken 
for  any  other  disease,  although  isolated  ca»ses  are  often  con- 
founded with  cholerine  or  with  cholera  morbus,  the  points 
of  distinction  being  very  few.  The  "comma  bacillus,"  how- 
ever, is  present  only  in  the  discharge  of  true  Asiatic  cholera. 

Concerning  the  diagnosis  between  Asiatic  cholera  and  cholera 
morbus.  Osier  says:  "  It  is,  of  course,  extremely  important  to  be 
able  to  diagnose  between  the  two  affections.  This  can  only  be 
done  by  one  thoroughly  versed  in  bacteriological  methods,  and 
conversant  with  the  diversified  flora  of  the  intestine." 

Prognosis. — Very  unfavorable,  the  mortality  ranging  from 
30  to  80  or  even  90  per  cent.  The  prognosis  is  controlled  by 
the  general  condition  of  the  patient,  the  age,  habits,  and  the 
development  of  the  algid  state;  it  is  more  favorable  in  those 
cases  which  develop  gradually  than  in  those  in  which  it  reaches 
its  acme  at  a  single  bound ;  the  very  young  or  very  old,  those 
addicted  to  excesses  and  surrounded  by  unfavorable  hygienic 
conditions,  are  more  apt  to  perish  than  are  others. 

Treatment. — The  treatment  should  always  be  instituted  as 
early  as  possible,  the  arrest  of  the  disease  in  the  diarrheal  stage 
being  comparatively  easy,  while  in  the  stage  of  collapse  it  is 
an  exceptional  occurrence. 

Strict  quarantine  must  be  immediately  established;  the 
health  authorities  should  be  notified  of  all  suspicious  cases; 
"concealment  is  a  crime  against  humanity," 


lOO  CHOLERA. 

The  prophylatic  treatment  consists  in  isolation  of  the  patient, 
sterilization  of  the  discharges  by  chlorinated  lime  or  carbolic  acid, 
boiling  of  all  bed-linen,  napkins,  towels,  dishes,  knives,  etc., 
and,  in  the  event  of  death,  wrapping  the  patient  in  sheets  soaked 
in  bichlorid  of  mercury  solution  (i  to  looo)  until  removed 
for  prompt  burial  or  (preferably)  cremation.  Attendants 
on  cholera  patients  should  avoid  direct ,  communication  with 
other  individuals,  and  should  be  careful  to  thoroughly  wash 
the  hands  after  contact  with  the  patient,  and  to  protect  the  hair, 
the  clothing,  and  the  shoes  by  some  covering  that  may  be 
easily  discarded.  Non-infected  individuals  in  cholera  districts 
should  be  instructed  to  drink  none  but  sterilized  water  and 
milk  and  to  partake  only  of  light,  easily  digested  food.  The 
food  supply  should  be  protected  from  contamination  by  in- 
sects. Intemperance,  overwork,  excitement,  and  exposure 
to  cold  and  wet  should  be  avoided,  and  gastrointestinal  dis- 
turbances should  .  be  guarded  against.  Immunization  by 
means  of  protective  serums  has  been  practised  with  some 
degree  of  success,  but  has  not  yet  reached  perfection. 

Medicinal  Treatment. — The  patient  should  be  placed  in 
bed  at  once  as  soon  as  the  symptoms  of  diarrhea  present  them- 
selves and  all  food  temporarily  withheld.  Calomel  (begin- 
ning with  two  or  three  doses  of  gr.  vii  (0.45  gm.),  followed 
with  small  doses,  gr.  3/4  (0.048  gm,),  every  two  hours)  is  of 
value  in  the  prodromal  stage,  especially  if  there  is  any 
indigestible  food  present  in  the  gastrointestinal  tract  (Ziems- 
sen).  The  opiates,  mineral  acids,  and  intestinal  antiseptics 
are  of  great  value  in  the  early  stage.  The  following  formula, 
recommended  by    Bartholow,    is   productive   of   great   benefit: 

I^.     Acid,  sulphuric  aromat  .    f5v  20.  c.c. 

Tinet.  opii  deodorat f  5iii  12.  c.c. 

M.  S. — Ten  to  20  drops  in  water  every  two  hours. 

Any  of  the  mineral  acids,  hydrochloric,  nitromuriatic,  or 
sulphuric,  in  doses  of  ttlx  to  xv  (0.66  to  i  c.c),  of  the  dilute 
acid  are  valuable,  especially  when  combined  with  paregoric 
or  laudanum.     Squibb's  cholera  mixture  may  also  be  employed: 


CHOLERA.  lOI 

I^.     Tr.  opii, 

Spts.  camphorae, 

Tr.  capsici aa  f  oi  30.  c.c. 

Chloroformi  pur f  5iii  12  .  c.c. 

Alcohol q.  s.  ad  f  §v  150.  c.c. 

M.  S. — Teaspoonful  every  two  hours. 

The  formula  of  the  "Sun  Cholera  Mixture"  is: 

I^.     Tr.  opii, 

Tr.  capsici, 

Tr.  rhei, 

Spt.  camphorae, 

Spt.  menthse  pip aa  f5i  30.  c.c. 

M.  S. — Teaspoonful  in  water  after  each  evacuation  of  the 
bowels. 

The  following  prescription  is  also  employed  in  this  stage: 

I^.     Tr.  opii, 

Tr.  capsici, 

Tr.  zingib., 

Spt.  menth.  pip., 

Spt.  chloroformi, 

Spt.  camphorae .  .aa  f  oss  2  .  c.c. 

Spt.  vin.  rect .  .  .  .q.  s.  ad       f  oii  60.  c.c. 

M.    S. — Teaspoonful  in   hot   water    every   fifteen   minutes 
until  relief  is  afforded. 

Intestinal  antiseptics,  such  as  bismuth,  salol,  lead  acetate, 
etc.,  may  be  used  with  benefit.  Peroxid  of  hydrogen  inter- 
nally has  been  used  with  success. 

I^.   .  Hydrogen  perox,id f  5ii  60.  c.c. 

Aquae  destillat f  Bviii  240.  c.c. 

M.  S. — Cupful  every  two  hours. 

Enteroctysis  or  irrigation  of  the  intestinal  canal  with  large 
amounts,  from  one  to  three  gallons  twice  daily,  of  hot,  soaped 
water,  hot  4  per  cent,  solutions  of  hydrogen  peroxid,  or  weak 
solutions  of  tannin,  or  hot  i  per  cent,  solution  of  common  salt. 


I02  CHOLERA. 

The  enteroclysis  is  accomplished  by  means  of  a  soft-rubber  tube, 
I  meter  in  length  and  of  suitable  size,  to  be  introduced  into  the 
rectum,  in  front  of  the  promontory  of  the  sacrum,  into  and  up 
through  the  sigmoid  flexure,  and  into  the  descending  colon. 
This  tube,  which  is  connected  with  a  reservoir,  should  not  be 
too  small  nor  too  large  in  order  to  facilitate  its  introduction 
through'  the  folds  of  the  sigmoid  portion  of  the  lower  bowel. 
In  fact,  the  greatest  difficulty  is  in  passing  the  tube  in  front  of 
the  promontory  of  the  sacrum  and  causing  it  to  enter  into  the 
sigmoid  flexure.  The  tube  should  be  of  proper  firmness  to  pre- 
vent it  from  bending  or  buckling  upon  itself  when  the  end 
(which  in  all  cases  should  be  rounded)  comes  in  contact  with  the 
obstructing  folds  of  the  intestine. 

In  the  second  stage  the  indications  are  to  relieve  the  pain 
and  cramps,  check  the  discharges,  and  to  upport  the  patient. 
The  distressing  vomiting  will  call  for  the  use  of  lavage  of  the 
stomach  with  hydrogen  peroxid  (2  ounces  to  the  quart  of  hot 
water),  iced  champagne,  cocain,  or  hydrocyanic  acid.  Ice  or 
carbonated  waters  may  be  given  to  allay  the  thirst.  Mor- 
phin  hypodermically  is  of  greatest  value  in  relieving  the  mus- 
cular   cramps.      Bartholow  advises  the  following  prescription: 

I^.     Chloarl 5iij  12 .       gm. 

Morphinae  sulphat gr.  iv  .26  gm. 

Aquae  lauro-cerasi f  5  j  30 .       c.c. 

M.  S. — For  hypodermic  injection.  Dose  15  to  30  minims. 

Locally,  hot  applications,  hot  irons,  hot  bricks,  hot-water 
bottles,  etc.,  or  an  ointment  of  chloroform  or  chloral  will  be  of 
service.  Inhalations  of  chloroform  or  ether  may  be  neces- 
sary. Brandy,  whiskey,  ammonia,  strychnin,  etc.,  should 
be  administered  to  sustain  the  patient.  Subcutaneous,  in- 
travenous, and  rectal  injections  of  hot,  normal  salt  solution 
(teaspoonful  of  salt  to  quart  of  water)  are  necessary  to  com- 
pensate for  the  fluid  lost  by  the  discharges.  The  astringent 
rectal  irrigations  should  be  continued.  When  the  patient 
becomes  algid,  hot  baths  and  hot  applications  should  be 
employed. 


DYSENTERY. 


103 


In  the  stage  of  reaction,  feeding  is  renewed,  peptonized 
milk,  milk  and  lime-water,  gruels  and  similar  liquid  foods 
being  allowed.  Tonics,  such  as  iron,  arsenic,  quinin,  etc.,  should 
be  given. 

DYSENTERY. 


Synonym. — Bloody  flux. 

Definition. — An  acute  inflammation  of  the  mucous  membrane 
of  the  large  intestine;  either  catarrhal  or  croupous  in  char- 
acter, followed  in  some  cases  with  ulceration,  charac  erized  by 
fever,  tormina,  tenesmus,  and  frequent,  small,  mucous,  and 
bloody  stools.  It  may  be  sporadic,  endemic  or  epidemic  and 
occurs  in  four  clinical  forms:  acute  catarrhal,  amebic  or  trop- 
ical,   bacillary,  and  chronic  dysentery. 

Causes. — The  predisposing  causes  of  all  forms  are  summer  and 
autumn  seasons,  warm  climate,  sudden  atmospheric  changes, 
errors  in  diet,  impure  drinking-water,  exposure 
to  cold  and  wet,  cachectic  states,  and  bad 
hygiene. 

The  catarrhal  form  is  usually  brought  about 
by  the  ingestion  of  irritating  food.  It  is  spor- 
adic and  is  not  associated  with  any  specific 
microorganism.  It  frequently  accompanies  the 
infectious  fevers.  This  form,  if  prolonged,  con- 
stitutes chronic  dysentery. 

The  amebic  or  tropical  dysentery  is  due  to  the 
presence  of  a  protozoon — the  AmcFba  coli — in 
the  colon.  The  organism  is  from  15  to  20  microns  in  diameter 
and  consists  of  a  central  portion  of  granular  protoplasm  sur- 
rounded by  a  narrow  zone  of  clear  protoplasm.  The  organism 
may  be  found  in  the  stools,  in  the  ulceration  of  the  colon,  and 
in  the  hepatic  abscesses  that  not  uncommonly  result.  This 
variety  of  the  disease  may  be  sporadic  or  epidemic. 

Bacillary  dysentery  (sometimes  called  croupous  or  diphther- 
itic dysentery)  is  due  to  the  Bacillus  of  Shiga,  a  microorganism 
belonging    to    the    colon-typhoid    group    of    bacilli    possessing 


Fig.  17. — Amoeba 
coli.  (After  Braun.) 
(From  Greene's  Aled- 
ical  Diagnosis.) 


I04  DYSENTERY. 

fiagella  and  motility.  It  produces  an  agglutination  reaction 
with  the  blood  of  dysenteric  patients  similar  to  the  Widal  test. 
This  variety  of  the  disease  is  common  in  temperate  and  tropical 
regions,  occurring  as  pseudomembranous,  croupous,  ulcerative, 
and    chronic    dysentery.      It    may    be    epidemic    or    sporadic. 

Dysentery  is  not  contagious  in  the  ordinary  sense  of  the 
word,  but  is  infectious,  the  drinking-water  being  the  usual 
medium  of  infection. 

Pathologic  Anatomy. — In  the  catarrhal  form  the  mucous 
membrane  and  submucous  coat  of  the  colon  are  swollen,  con- 
gested, and  edematous,  and  mucus  is  formed  in  excess.  The 
follicles  are  enlarged  and  may  become  ulcerated. 

In  amebic  or  tropical  dysentery  the  lesions  are  situated  also 
in  the  colon,  but  may  be  found  in  the  ileum.  Ulceration, 
involving  the  mucosa  and  submucosa,.  is  the  characteristic 
structural  change.  This  process  is  preceded  by  the  infiltra- 
tion of  the  mucous  and  submucous  coats  with  a  grayish,  gelat- 
inous substance,  the  exfoliation  of  which  produces  the  ulcer. 
In  the  early  stages  these  local  infiltrations  appear  as  hemis- 
pheric elevations,  the  mucous  membrane  covering  which  is 
soon  cast  off  to  be  followed  by  sloughing  of  the  submucous 
coat  and  its  infiltrate.  The  microorganisms  are  present  in 
the  necrotic  tissue  and  by  their  migration  not  infrequently 
(20  per  cent.)  produce  abscess  of  the  liver. 

Bacillary,  croupous,  or  diphtheritic  dysentery  begins  with 
intense  congestion,  swelling,  and  edema  of  the  mucous  and 
submucous  tissue,  with  extravasations  of  blood,  and  the  whole 
mucous  membrane  is  covered  with  a  firm,  fibrinous  exudation ; 
the  mucous  membrane  softens  and  sloughs,  leaving  large 
ulcers  and  gangrenous  spots.  If  recovery  occurs,  large  cicatrices 
form,  which  narrow  the  caliber  of  the  intestinal  tube.  The 
mesenteric  glands  enlarge  and  soften,  and  abscesses  form  in 
them  the  liver  becomes  the  seat  of  small  abscesses,  from  em- 
bolic obstruction  of  the  radicles  of  the  portal  vein;  the  heart 
muscle  is  flabby  and  more  or  less  fatty. 

Symptoms. — The  catarrhal  form  begins  gradually,  with  diar- 
rhea,  loss  of  appetite,   nausea,   and  very  slight  fever,   which 


DYSENTERY.  IO5 

continues  for  two  or  three  days,  when  the  true  dysenteric 
symptoms  develop,  viz.,  pain  on  pressure  along  the  trans- 
verse and  descending  colon,  tormina  or  colicky  pains  about 
the  umbilicus,  burning  pain  in  the  rectum,  with  the  sensation 
of  the  presence  of  a  foreign  body  and  a  constant  desire  to  expel 
it,  or  tenesmus.  The  stools  for  the  first  day  or  two  contain 
more  or  less  fecal  matter,  but  they  soon  change  to  a  grayish, 
tough,  transparent  mucus,  containing  more  or  less  blood  and 
pus.  The  number  of  stools  varies  from  five  to  twenty  or  more 
in  the  twenty-four  hours.  During  the  tormina,  nausea  and 
vomiting  may  occur.  The  urine  is  scanty  and  high-colored. 
The  duration  is  about  one  week,  the  patient  rapidly  becoming 
emaciated  and  enfeebled. 

The  amebic  form  is  characterized  by  a  more  gradual  onset 
and  gradually  increasing  diarrhea.  The  stools  are  frequent, 
bloody,  mucoid,  and  very  fluid,  but  as  the  disease  progresses 
they  become  yellowish-gray  and  contain  mucus  and  some- 
times blood.  The  stools  are  less  in  number  and  the  tenesmus 
is  not  so  great  as  in  the  preceding  variety  Actively  moving 
amcehcB  coU  are  found  in  the  evacuations,  disappearing  as  the 
stools  become  formed.  Fever  is  not  very  high  and  may  be 
absent.  Emaciation  is  marked.  Abscess  of  the  liver  and 
lungs  may  occur  as  complications.  The  duration  varies  from 
six  to  twelve  weeks  and  convalescence  is  protracted.  Periodic 
recrudescences  are  not  uncommon. 

The  hacillary  variety  has  an  acute  onset.  The  stools  are 
mofe  frequent  and  contain  more  blood  and  pus,  patches  of 
membrane,  sometimes  casts  of  the  bowel,  and  portions  of  the 
gangrenous  mucous  membrane.  Nausea,  vomiting,  and  great 
prostration  and  emaciation  are  present.  The  skin  is  cold, 
the  pulse  is  feeble,  and  the  odor  emanating  from  the  patient 
is  fetid.  Gaseous  distention  of  the  abdomen  is  common.  The 
fever  is  high;  the  tenesmus  is  severe;  and  the  adynamia  is  pro- 
found. The  bacillus  of  Shiaga  is  present  in  the  discharges. 
The  duration  of  the  grave  symptoms  is  three  or  four  days, 
when  collapse  and  death  occur  or  protracted  convalescence 
begins.     Hepatic     abscess,     intestinal     perforation,     arthritis. 


I06  DYSENTERY. 

and  paralysis  may  occur  as  complications.  This  variety  of  the 
disease  may  become  chronic  and  may  occur  in  the  course  of 
heart,  lung,  or  kidney  disease. 

Chronic  Dysentry. — A  persistence  in  the  intestinal  lesions 
of  any  of  the  acute  varieties  just  described  results  in  chronic 
dysentery;  but  bacillary  dysentery  is  the  form  that  usually 
tends  to  become  chronic.  Ulceration  is  present  in  most  cases, 
but  in  others  the  intestinal  walls  are  thickened  with  scattered 
slate-colored  patches  of  blood  extravasation  and  distintegra- 
tion.  Diarrhea  and  emaciation  are  the  principal  symptoms. 
Abdominal  pain  and  tenesmus  are  slight.  Acute  exacerbations 
are  frequent.  The  affection  may  last  several  months  or  even 
years. 

Diagnosis. — The  blood-stained  stools,  tenesmus,  abdominal 
pain,  and  the  history  will  aid  in  distinguishing  dysentery  from 
other  enteric  conditions.  The  variety  of  the  disease  may  be 
recognized  by  the  microorganisms  in  the  stools  and  the 
symptoms. 

Acute  catarrhal  enteritis  is  not  attended  by  tenesmus  or 
blood-stained  mucoid  stools. 

Malignant  rectal  disease  is  attended  by  blood-stained  stools 
and  tenesmus  and  resembles  chronic  dysentery,  but  an  examina- 
tion will  serve  to  clear  up  the  diagnosis. 

Intussusception  is  accompanied  by  mucoid  and  bloody 
stools  with  tenesmus,  but  the  abrupt  onset,  persistent  vomiting, 
and  the  presence  of  a  sausage-shaped  tumor  n  the  abdomen 
will  distinguish  it  from  dysentery. 

Treatment. — The  patient  should  be  confined  to  bed  in  even 
the  mildest  attack,  and  the  bed-pan  employed,  being  careful 
to  thoroughly  disinfect  the  discharges  with  ferrous  sulphate 
or  chlorinated  lime.  The  diet  should  be  bland  and  unirritat- 
ing.  Substances  such  as  milk  and  lime-water,  beef-peptonoids, 
broths,  egg-albumin,  etc.,  may  be  given  in  acute  attacks.  A 
seriiisolid  diet  is  permissible  in  chronic  cases.  The  medicinal 
treatment  should  be  begun  by  the  administration  of  a  purgative, 
preferably  castor  oil,  oj  (30  c.c),  with  tincture  of  opium,  gtt. 
X  to  XX  (0.65  to  1.33  gm.).     When  there  is  high  fever  and  no 


DYSENTERY.  lO 


marked  evidence  of  adynamia,  magnesium  sulphate,  oii  (8.  gm.), 
or  Rochelle  salt,  oiv  (i6.  gm.),  may  be  given  in  water  every 
hour  until  there  is  copious  purgation  (Saline  Treatment). 

The  pain,  tenesmus,  and  peristalsis  will  require  opium  in 
some  form,  alone  or  combined  with  astringents.  A  hypoder- 
mic injection  of  morphin  sulphate,  gr.  1/4  to  1/2  (0.016  to 
0.032  gm.),  given  every  three  or  four  hours  as  required  is  very 
efhcient. 

J\.      Ext.  opii gT-  ss  .032  gm. 

Plumbi  acetat gf-  ij  .13     gm. 

M.  S. — Every  two  hours. 

Or— 

I^ .     Pulv.  opii gr •  ss  .032  gm. 

Plumbi  acetat gr-  ij  .13     gm. 

Pulv.  ipecac gr.  1/4  .016  gm. 

M.  S. — Every  two  hours,  until  character  of  stools  changes. 
Good  results  have  followed  the  use  of  Mistura  enterica: 

I^.      Acid  sulph.  dil f  §ss  15.  c.c. 

Tinct.  opii  deodorat f  03  30.  c.c. 

Spts.  camphorae f  §j  30.  c.c. 

Tinct.   capsici f  5ss  15.  c.c. 

Spts.  chloroformi f  5ss  15  .  c.c. 

Spts.  vini  gallici f  oiss  45  .  c.c. 

M.  S. — One  teaspoonful  every  two  or  three  hours,  diluted. 

In  strong  young  individuals  the  very  best  prescription  pos- 
sible  is: 

I^.      Magnesii  sulph 3j  4-     gm. 

Acid,  sulph.  dil n^x  .  6  c.c. 

Tinct.  opii  deodorat ir^x  .6  c.c. 

Aquae  chloroformi .  q.s.ad  Sij  ad   8.     c.c. 
M.   S. — To  be  given  every  two  or  three  hours  until  feces 

appear  in  the  stools  when  small  doses  of  opium  and  quinin 
sulphate  may  be  used. 


I08  DYSENTERY. 

Hope's  original  camphor  mixture  at  times  acts  favorably: 

I^.      Acidi  nitrosi f  5i  4 .  gm. 

Mist,  camphorae f  Bviii  240.  gm. 

M.  et  adde 

Tr.  opii gr.  xl  1.2  gm. 

M.  S. — One-fotirth  of  this  mixture  to  be  taken  every  three 
or  four  hours. 

Bismuth  subnitrate,  gr.  xxx  (2  gm.),  or  bismuth  salicylate, 
gr.  XX  (1.3  gm.),  every  two  or  three  hours  is  of  value.  Loomis 
recomm^ends  ipecacuanha,  gr.  1/4  (0.016  gm.),  every  half-hour 
with  sufficient  opium  to  secure  quietness.  The  East  Indian 
physicians  employ  it  in  amebic  and  bacillary  dysentery  in 
large  doses,  20  to  60  gr.  (1.332  to  4  gm.).  Its  administration 
is  preceded  by  a  dose  of  tincture  of  opium  one-half  hour  be- 
fore; and  for  three  hours  previously  no  food  is  allowed.  On  the 
second  day  the  dose  of  ipecacuanha  is  reduced  and  the  drug  is 
combined  with  intestinal  antiseptics. 

In  children  the  following  combination  is  successful: 

i^.     Pulv.  ipecacuanhae gr.  1/4      .016  gm. 

Bismuth,  subnitrat gr.  v  to  x  .  32  to .  65  gm. 

Cretae  prsep gr.  iij         .  2  gm. 

M.   S. — Every  two  hours. 

Ringer  advocates  the  use  of  bichlorid  of  mercury,  gr.  i/ioo 
(0.00065  g^^-)>  every  hour  or  two,  claiming  that  it  soon  frees 
the  evacuation  of  blood  and  slime.  Nuclein,  gr.  i  (0.065  g^^O^ 
every  hour,  until  the  character  of  the  stools  changes,  is  also  of 
value. 

Serum  Treatment. — The  antidysenteric  serum  obtained  from 
the  horse  after  immunization  has  been  employed  on  animals 
in  the  laboratory  with  success.  Shiga  has  used  it  in  many  cases 
of  Japanese  dysentery  with  a  mortality  of  about  10  per  cent, 
which,  under  the  ordinary  methods  of  treatment,  would  have 
been  about  36  per  cent. 

Irrigation  of  the  rectum  with  either  tepid,  hot,  cold,  or  iced 
water  adds  greatly  to  the  patient's  comfort  and  to  the   de- 


DYSENTERY. 


109 


crease  of  the  inflammatory  process.  A  i  to  2  per  cent,  solution  of 
creolin  may  be  used.  Osier  employs  warm  injections  of  quinin, 
I  to  5000,  I  to  2500,  in  amebic  dysentery  with  great  benefit 
and  rapid  destruction  of  the  amebae.  Suppositories  of  ice, 
iodoform,  or  opium  will  afford  great  relief,  lessening  the  pain 
and  tenesmus. 

Poultices,  stupes,  hot-water  bottles,  etc.,  may  be  applied 
over  the  abdomen,  but  are  seldom  very  beneficial. 

Chronic  dysentery  will  require  careful  modification  of  the 
diet,  and  rest  in  bed.  Internally,  bismuth  subnitrate,  gr.  xxx 
(2.  gm.),  three  times  daily;  turpentine,  tt^x  (0,6  c.c),  every 
three  hours;  silver  nitrate,  gr.  1/8  to  1/3  (0.008  to  0.022  gm.), 
three  times  daily;  sulphur,  gr.  x  (0.6  gm.),  three  times  daily; 
or  the  following  nxay  be  administered : 

I^.     Cupri  sulphat ...    gr.  1/6  o.ciigm. 

Ext.  opii gr.  1/4  0.0x6  gm. 

Ext.  nucis  vomicae gr.  1/6  o.oiigm. 

M.     Ft.  pil.  No.  i. 

S. — To  be  taken  four  times  daily. 

Cases  which  are  continued  by  reason  of  ulcerated  patches 
in  the  colon  require  intestinal  irrigations.  Silver  nitrate,  gr. 
x  to  xxx  (0.6  to  2.  gm.)  to  the  pint,  is  the  solution  of  selection. 
The  patient  should  be  placed  on  the  back  with  the  hips  elevated. 
The  preliminary  injection  of  a  small  quantity  of  cocain  (4  per 
cent,  solution)  will  relieve  any  irritability  of  the  rectum.  The 
irrigating  solution  is  allowed  to  flow  into  the  bowel  through  a 
long  rubber  tube  connected  to  a  fountain  syringe,  the  bag 
portion  of  which  is  elevated.  The  injection  should  be  made 
from  two  to  three  times  a  week,  employing  from  i  to  3  pints 
or  more  of  the  solution.  Alum,  sulphate  of  zinc,  acetate  of 
lead,  or  copper  sulphate  may  be  used  instead  of  silver  nitrate 
in  solution.     The  following  is  sometimes  given  by  injection: 

I^.     Argent,  nitrat gr.  i  0.065  gm. 

Tr.  opii  deodorat ni^"v-  i .         gm. 

Aquae  amyli f§iv  120.         gm. 

M.  S. — Use  as  directed. 


no 


TRYPANOSOMIASIS . 


During  convalescence,  the  internal  administration  of  cod- 
liver  oil,  syrup  of  the  lactophosphate  of  lime,  and  the  follow- 
ing combination  will  be  required: 

I^.      Strychnin,  sulphat gr-  ss  0.032  gm. 

Acid,  hydrochlor.   dil.  .  .    f  5ii  8.  gm. 

Tr.  gent.  comp.  q.    s.  ad  foiv  120.  gm. 

M.  S. — One  teaspoonful  in  water  before  meals. 


TRYPANOSOMIASIS. 

An  infectious  condition  produced  by  the  presence  of  several 
varieties  of  trypanosomes,  especially  trypanosoma  gamhiense. 
The  importance  of  the  condition  arises  from  its  intimate  re- 
lation with  sleeping  sickness,  a  common  malady  in  Africa.     The 

parasites  gain  entrance  to  the  body  by 
means  of  bites  of  the  tsetse-fly,  the  inter- 
mediate host,  but  it  is  also  reasonable  to 
suppose  that  contaminated  drinking-water 
is  a  cause  since  most  cases  have  been  ob- 
served in  regions  near  the  water's  edge. 
Among  the  symptoms  of  trypanosomi- 
asis may  be  mentioned  irregular,  undulant 
fever,  especially  in  Europeans,  cutaneous 
eruptions,  muscular  weakness,  drowsiness, 
rapid  pulse,  anemia,  breathlessness,  inor- 
dinate appetite,  and  various  ocular  mani- 
festations. The  lymphatic  glands  are 
usually  enlarged  and  sometimes  the  size 
/T^    Trypanosoma   of  the   Spleen  is  increased.     The  parasite 

(Dutton  and  Lav-  ^  .  ^ 

may  be  found  in  the  blood  and  the  cere- 
brospinal fluid. 

The  parasites  also  attack  horses,  rats,  monkeys  and  fish. 
African  negroes  are  particularly  susceptible  to  the  di  ease,  but 
the  prognosis  is  better  in  these  individuals  than  in  Europeans 
visiting  infected  districts.  No  cases  have  been  observed  in 
x\merican  negroes.     There  seems  to  be  no  acquired  immunity. 


Fig. 
hominis 
eran.)     {From  Greene  s  Med 
ical  Diagnosis.) 


BUBONIC    PLAGUE.  1  1  i 

The  mortality  is  high  and  treatment  is  ineffectual.  The  best 
results  have  been  obtained  from  the  administration  of  arsenic 
(Fowler's  solution  in  doses  of  5  minims,  gradually  increased  to 
10  or  12  minims),  and  of  atoxyl.  Prophylaxis  consists  in  pro- 
tection from  the  bite  of  the  tsetse-fly. 

BUBONIC  PLAGUE. 

Synonyms. — Black  death;  plague;  oriental  plague. 

Definiton. — A   specific,    infectious   disease   of   extraordinary 
virulence  and  very  rapid  course,   characterized  by  inflamma- 
tion of  the  lymphatic  glands  (buboes),  carbuncles,  pneumonia, 
and  often  hemorrhages   (Osier). 

Etiology. — The  specific  cause  is  the  bacillus  pestis,  isolated 
by  Kitasato,  which  gains  entrance  to  the  body  through  the 
respiratory  and  digestive  tracts  and  abrasions  of  the  skin  sur- 
face. The  infection  is  conveyed  solely  by  the  flea  on  the  rat. 
Hot  weather  and  faulty  hygiene  influence  the  et.'ology  in- 
directly, by  favoring  infestation  by  rats. 

Symptoms. — The  disease  begins,  after  an  incubation  period 
of  a  few  days  to  a  week,  with  extreme  prostration.  This  is 
followed  by  fever  (and  its  attendant  phenomena)  which  soon 
assumes  a  typhoid  type.  Hemorrhages  into  the  skin  and 
mucous  membranes  are  common.  The  lymphatic  glands 
enlarge,  and  on  the  second  or  third  day  suppurating  buboes 
appear  in  the  groin,  neck,  or  armpit,  which  usually  rupture 
and  discharge.  The  temperature  drops  with  the  appearance 
of  the  buoes  and  there  is  profuse  sweating. 

Prognosis. — The  mortality  varies  from  70  to  90  per  cent. 
Death  occurs  usually  on  the  second  or  third  day. 

Treatment. — The  best  prophylactic  measure  is  to  kill  the  rats, 
or  at  any  rate  to  keep  them  outside  of  the  dwellings.  During 
the  course  of  the  disease  the  patient  should  be  made  as  com- 
fortable as  possible  and  the  symptoms  combated  as  they  arise. 
Purgation  and  stimulation  are  often  of  value.  Morphin  is 
necessary  for  the  .relief  of  the  pain.  Locally,  the  injection 
of   bichlorid   of   mercury   into   the   buboes   has   given   good  re- 


112  TETANUS. 

suits.  Haffkine  employs  a  preparation  of  sterilized  bouillon 
cultures  for  prophylactic  purposes  which  has  met  with  some 
degree  of  success.  Other  serums  have  also  been  used.  Ac- 
cording to  Kitasato,  the  disease  may  to  a  large  extent  be 
prevented  by  the  observance  of  well-known  hygienic  rules. 
The  sewerage  system  should  be  of  a  sanitary  character  and 
the  food  and  drink  supply  should  be  protected  from  con- 
tamination. Furniture,  clothing,  utensils,  etc.,  should  be  dis- 
infected as  in  other  highly  contagious  diseases.  The  s  ools  and 
other  excreta  should  be  mixed  with  lime  before  being  finally 
disposed  of.  The  dead  should  be  cremated  or  buried  at  a 
depth  of  3  meters.  In  case  of  recovery,  the  patient  should 
be  kept  isolated  for  a  period  of  at  least  one  month  afterward. 

TETANUS. 

Synonyms. — Lockjaw;  trismus. 

Definition. — An  acute  or  subacute  infectious  disease,  charac- 
terized by  muscular  rigidity,  with  paroxysms  of  tonic  con- 
vulsions which  recur  with  increasing  severity,  the  mind  remain- 
ing clear. 

Varieties. 

Idiopathic  tetanus  when  no  open  wound  is  discoverable. 

Traiiniatic  tetanus  when  an  open  wound  is  present. 

Tetanus  neonatorum   when  it  attacks  infants. 

Lockjaw  or  trismus  when  the  jaw  alone  is  involved. 

Cephalic    tetanus    when    the    throat    and    face    are    affected. 

Cause. — The  result  of  a  specific  bacillus — the  bacillus  tetani — 
which  usually  gains  access  o  the  system  through  an  abrasion. 
The  incubation  period  is  from  ten  to  fifteen  days. 

Pathologic  Anatomy. — In  the  post-mortem  examinations 
which  have  been  made,  no  uniform  morbid  appearance  was 
discovered  on  microscopic  examination.  The  brain,  cord, 
lungs,  and  muscles  are  markedly  congested,  and  show  minute 
hemorrhages,  such  as  are  met  with  in  all  cases  of  death  from 
convulsions,  and  which  occur  chiefly  during  the  process  of 
death. 


TETANUS.  113 

Symptoms. — The  onset  is  rather  sudden,  with  stiffness  of 
the  jaw,  neck,  and  tongue,  and  some  difficulty  in  swallowing, 
which  increases  in  extent,  the  stiffness  passing  down  the  spi- 
nal muscles  to  the  legs,  which  are  held  in  a  firm  spasm.  Gradu- 
ally tonic  spasms  develop  which,  involving  the  jaw  muscles, 
cause  "lockjaw";  the  face  muscles,  '' risus  sardonicus" ;  neclc 
and  trunk  muscles,  so  that  the  patient  rests  on  his  head  and 
heels,  "opisthotonos"  ;  the  trunk  and  limbs  may  be  rigid,  "  ortho- 
tonos"  ]  the  body  may  be  bent  forward,  "  emprosthotonos" ;  or 
bent  to  one  side,  "  plenrosthotonos" ;  these  tonic  convulsions 
are  associated  with  intense  pain  and  the  patient  suffers  the 
greatest  distress,  particularly  if  the  chest  muscles  are  involved. 
Usually  the  febrile  reaction  is  slight,  but  in  many  cases  102° 
to  104°  F.  is  reached,  and  in  some  instances,  as  death  approaches, 
108°  to  110°  F.,  rising  still  higher  after  death.  The  pulse  may 
reach  130  to  150  and  the  respirations  30  to  45.  The  mind 
remains  clear  till  the  end,  death  being  due  to  exhaustion;  but 
sometimes  carbon  dioxid  poisoning  occurs.  Usually  a  wound, 
not  severe,  can  be  found,  the  symptoms  developing  some  two 
weeks  after  its  occurrence.  The  tonic  spasms  are  developed 
by  many  sources  of  irritation,  a  draught  of  air,  shaking  of  the 
bed  or  floor,  suddenly  opening  the  door  of  the  room,  the  pres- 
ence of  a  visitor,  or  attempts  at  speaking  or  movement. 

Diagnosis. — The  symptoms  are  so  characteristic,  with  the 
addition  of  a  history  of  a  wound,  that  an  error  seems  hardly 
probable. 

Tetany.  The  spasms  chiefly  affect  the  extremities,  the 
muscles  being  free  in  the  interval  and  trismus  a  late  or  very 
rare  condition. 

Strychnin  poisoning  often  closely  resembles  tetanus,  but 
there  is  no  beginning  trismus  and  more  rapid  development  of 
the  symptoms;  the  spasms  affect  the  entire  body,  and  in  the 
intervals  between  the  spasms  the  muscles  are  relaxed.  No 
history  of  wound. 

Hydrophobia  does  not  have  trismus,  but  respiratory  spasm, 
excited   by   attempts    at    swallowing,    with    increasing   mental 
symptoms. 
8 


114  HYDROPHOBIA. 

Prognosis. — Unfavorable.     The  great  majority  die. 

Treatment. — The  patient  should  be  placed  at  absolute  rest 
in  bed  in  a  quiet  and  darkened  room.  If  seen  early  the  wound 
should  be  thoroughly  cauterized  or  excised  and  antisepticized. 
The  spasms  will  require  the  administration  of  drugs  such  as 
chloral,  potassium  bromid,  chloralamid,  morphin  sulphate, 
physostigma,  and  antipyrin.  Inhalations  of  chloroform  or 
amyl  nitrite  are  often  necessary.  The  administration  of 
tetanus  antitoxin  by  subcutaneous  injec  on  has  been  followed 
by  successful  results  in  a  number  of  cases;  but  it  must  be  done 
promptly,  before  symptoms  develop.  Its  chief  use  is  as  a 
prophylactic,  and  it  should  be  used  in  conjunction  with  other 
remedies.  Nutrition  must  be  maintained  by  rectal  alimenta- 
tion. The  hypodermic  injection  of  carbolic  acid,  gr.  iii  (0.2  gm.) 
a  day,  increasing  rapidly  until  gr.  vi  to  viii  (0.4  to  0.5  gm.) 
daily  is  reached,  has  been  highly  recommended.  Bacelli  em- 
ploys a  2  per  cent,  solution  hypodermically  every  three  hours. 
Recently,  subarachnoid  injections  of  magnesium  sulphate  have 
been  employed;  15  minims  of  a  25  per  cent,  solution,  are  used 
at  intervals  of  24  or  48  hours. 

HYDROPHOBIA. 

4 

Synonym. — Rabies;  lyssa. 

Definition. — An  acute  infectious  disease,  occurring  in  the 
lower  animals,  but  communicable  to  man  by  inoculation, 
characterized  by  intense  tonic  spasm  beginning  in  the  larynx. 

Cause. — The  disease  is  due  to  a  specific  virus  which  gains 
entrance  to  the  general  circulation  of  man  by  means  of  the 
bites  of  rabid  animals.  The  poison  is  contained  in  the  medulla, 
brain,  and  secretions,  especially  the  saliva.  The  virus  is  sup- 
posed to  reach  the  dog's  salivary  glands  by  way  of  the  nerves 
and  not  through  the  blood-vessels.  Various  organisms  have 
been  found,  but  their  connection  with  the  disease  is  far  from 
proved.  The  affection  in  man  is  usually  contracted  through 
the  bite  of  a  rabid  dog.  However,  not  more  than  10  or  12  per 
cent,   of  those  bitten  by  dogs  become  affected.      Bites  on  the 


HYDROPHOBIA.  II5 

hands  and  face  are  especially  liable  to  be  infected  by  the  virus, 
because  these  parts  are  exposed;  the  clothing,  when  penetrated 
by  the  teeth,  removes  much  of  the  virus.  The  period  of  incu- 
bation varies  from  one  week  to  two  or  more  months.  If  no 
symptoms  manifest  themselves  within  three  months,  the  pa- 
tient may  be  considered  as  unlikely  to  develop  the  disease. 

Pathologic  Anatomy. — The  structural  changes  are  confined 
to  the  upper  spinal  cord,  medulla,  pons,  and  cerebral  cortex. 
Negri  has  described  in  the  central  nervous  system  irregular 
bodies  found  in  the  cells  of  these  parts ;  these  bodies  are  sup- 
posed to  be  protozoa  and  are  said  to  be  diagnostic.  The  blood- 
vessels are  dilated  and  overfilled,  the  perivascular  sheaths  are 
infiltrated  with  leukocytes,  and  small  hemorrhages  are  present. 
The  ganglia  of  the  cerebrospinal  and  sympathetic  systems 
undergo  characteristic  changes.  The  capsular  cells  of  the 
ganglia  proliferate  leading  to  destruction  of  the  ganglia,  with 
their  replacement  by  round  cells.  Occasionally  the  ganglion 
.cells  are  but  slightly  altered.  The  pharynx  larynx,  treachea, 
and   bronchi  are  hyperemic. 

Symptoms. — The  first  stage  lasts  about  twenty-four  hours 
and  begins  with  pain  in  the  wound  or  its  cicatrix,  depression 
of  spirit;  irritability,  intense  mental  anxiety,  feverishness, 
anorexia,  hoarseness,  sleeplessness,  and  hypersensitiveness  to 
noises.  This  is  followed  by  the  second,  spasmodic,  or  furious 
stage.  The  muscles  of  the  larynx  become  extremely  irritable 
and  contract  on  the  slightest  excitation,  thus  rendering  swal- 
lowing and  breathing  difficult.  Any  attempt  to  swallow  water 
or  the  accumulations  of  saliva  induces  the  paroxysms;  hence 
the  name  of  the  disease — hydrophobia — fear  of  water.  Hyperes- 
thesia is  marked,  so  much  so  that  even  a  breath  of  air  or  a 
slight  noise  may  cause  the  spasms.  Delirium  and  maniacal 
excitement  are  often  present.  Fever  (103°  F.)  is  observed  also 
in  this  stage,  and  the  pulse  is  irregular.  The  duration  is  from 
one  to  three  days.  In  the  third  stage  prostration  becomes 
marked  and  the  paroxysms  subside.  The  heart  gradually  fails. 
Death  follows  from  syncope,  or  asphyxia  from  convulsions. 
This  stage  lasts  from  six  to  eighteen  hours. 


Il6  ANTHRAX. 

Diagnosis. — Tetanus  is  distinguished  from  hydrophobia  by 
its  history,  short  incubation  period,  character  of  convulsions, 
and  absence  of  marked  throat  symptoms.  The  extreme 
mental  depression  is  also  absent  in  tetanus. 

Hysteria  in  persons  bitten  by  animals  may  simulate  hydropho- 
bia. Such  condition  is  sometimes  called  pseudohydrophobia  or 
lyssophohia.  Such  individuals  are  usually  neurotic  and  attempt 
to  bark  and  bite  and  show  many  manifestations  uncommon  in 
hydrophobia.  The  resemblance  is  often  very  close.  Subdural 
injections  in  rabbits,  of  the  central  nervous  system  of  the  animal 
supposed  to  be  rabid,  will,  in  true  hydrophobia,  be  followed  by 
the  paralytic  form  of  the  disease  in  fifteen  to  twenty  days. 

Prognosis. — After  the  disease  is  established  the  prognosis 
is  extremely  unfavorable.  Nearly  all  cases  die,  very  excep- 
tionally  spontaneous  recovery  occurs. 

Treatment. — Hydrophobia  can  be  prevented  by  a  systematic 
compulsory  muzzling  of  dogs;  in  parts  of  Germany  the  disease 
has  been  practically  eradicated.  When  a  dog  is  suspected,  it 
should  not  be  killed  but  it  should  be  tied  up  and  watched. 
Prompt  suction  followed  by  cauteriza  on  of  the  wound  with 
nitric  acid,  or  some  strong  caustic  or  the  actual  cautery  is  ad- 
vised; nitrate  of  silver  is  not  to  be  used  for  this  purpose.  The 
wound  should  be  kept  open.  Chloroform,  chloral,  opium,  etc., 
will  be  necessary  to  control  the  spasms.  Nutritive  enemas  will 
be  necessary  to  keep  up  the  patient's  strength.  The  Pasteur 
treatment,  consisting  of  a  series  of  inoculations  of  virus,  of 
increasing  strengths,  prepared  from  the  spinal  cords  of  infected 
rabbits,  should  be  tried  for  immunizing  and  curative  purposes. 
The  individual  bitten  by  a  rabid  animal  should  receive  this 
treatment  immediately.  The  treatment  is  harmless  to  a  non- 
infected  person. 

ANTHRAX. 

Synonyms. — Malignant  pustule;  wool-sorter's  disease;  char- 
bon;  splenic  fever. 

Definition. — An  acute  infectious  disease  produced  by  the 
bacillus  anthracis.     It  is  essentially  a  disease  of  the  lower  animals, 


ANTHRAX.  117 

especially  cattle  and  sheep,  but  may  be  transmitted  to  man  by 
contact  with  the  bodies  of  infected  animals.  Butchers,  stable- 
hands,  tanners,  wool-sorters,  etc.,  are  consequently  most  often 
attacked. 

Pathologic  Anatomy. — After  death,  the  body  appears  cyanotic ; 
carbuncles  or  gangrenous  areas  may  appear  on  the  skin;  the 
blood  is  black,  viscid,  and  coagulates  slowly.  The  gastro- 
intestinal membrane  is  edematous  and  ecchymotic  with  en- 
larged follicles  or  glands,  and  gangrenous  spots  in  which  the 
bacilli  may  be  found.     The  nervous  tis  ues  are  also  affected. 

Symptoms. — After  an  incuba  ion  period  of  about  one  week 
the  symptoms  begin  to  appear  and  may  for  convenience  be 
grouped  as  external  and  internal.  Ext  rnal  includes  malig- 
nant pustule  and  malignant  anthrax  edem.a. 

Malignant  pustule  begins  as  a  hemorrhagic  bleb  beneath 
which  a  gangrenous  eschar  with  a  dusky  red  infiltrated  areola 
forms.  It  is  attended  by  constitutional  symptoms  such  as 
.fever,  increased  pulse,  thirst,  etc.,  rapid  breathing,  enlarged  liver 
and  spleen,  and  followed  usually  by  death  within  a  few  days. 

Malignant  anthrax  edema  begins  on  the  face,  usually  about 
the  eyes,  and  extends  downward.  The  edema  is  so  great 
that  gangrene  results ;  and  this  form  is  even  more  fatal  than  the 
malignant  pustule. 

Internal  anthrax  is  also  of  two  kinds :  intestinal  anthrax,  and 
wool-sorter  s  disease. 

Intestinal  anthrax,  or  mycosis  intestinalis  may  begin  with 
chill,  nausea,  vomiting,  bloody  diarrhea,  abdominal  pain,  and 
tenderness.     It  is  due  to    eating  meat  infected  with  anthrax. 

Wool-sorter  s  disease  is  due  to  inhalation  of  the  bacilli  into  the 
lungs,  and  is  characterized  by  chill,  fever,  pain,  dyspnea, 
bronchitis,  and  cough.      It  is  generally  rapidly  fatal. 

Diagnosis. — The  diagnosis  can  be  made  by  the  history,  the 
character  of  the  patient's  occupation,  the  gangrenous  patches 
with  great  edema  and  infiltration,  the  marked  constitutional 
symptoms,  and  the  presence  of  the  bacillus  in  the  blood  and  the 
secretions. 

Prognosis  is  always  grave;  especially  in  the  internal  varieties. 


Il8  WHOOPING   COUGH. 

Treatment. — The  treatment  is  largely  prophylactic.  Con- 
taminated animals  should  be  destroyed  in  their  entirety  and 
disinfectants  freely  used  in  places  where  they  have  been  housed. 
In  man,  the  lesions  should  be  subjected  to  surgical  procedures, 
especially  incisions,  curetment,  and  deep  cauterization.  In- 
ternally, alcohol,  quinin,  and  other  supportive  drugs  should 
be  used  to  the  point  of  tolerance  on  account  of  the  profoundly 
typhoid  state.  Powdered  ipecac  in  doses  of  5  to  lo  gr.  (0.32  to 
0.64  gm.)  every  three  or  four  hours  has  been  recommended. 

WHOOPING  COUGH. 

Synonym. — Pertussis. 

Definition. — An  infectious  disease  characterized  by  a  con- 
vulsive paroxysmal  cough,  consisting  of  a  number  of  forcible 
expirations,  followed  by  a  series  of  deep,  loud,  sonorous  in- 
spirations (the  whoop),  repeated  several  times  during  each 
paroxysm,  and  associated  with  catarrh  of  the  bronchial  tubes. 

Causes. — The  disease  is  contagious  and  is  due  to  an  unknown 
microorganism  associated  with  the  sputum  and  mucous  dis- 
charges. It  is  a  disease  of  childhood,  fully  one-half  of  the  cases 
occur  during  the  first  two  years  of  life.  Adults  may  be  affected. 
One  attack  usually  secures  immunity. 

Pathology. — There  are  no  characteristic  structural  changes. 
The  poison  which  produces  the  disease  acts  on  the  nervous 
system  and  respiratory  mucous  membrane.  It  is  said  that 
"  irritation  of  the  internal  branch  of  the  superior  laryngeal 
nerve  produces  relaxation  of  the  diaphragm,  spasm  of  the 
glottis,  and  a  convulsive  expiration,  the  series  of  phenomena 
present  in  a  paroxysm  of  asthma."  There  is  also  hyperemia 
of  the  mucous  membrane  of  the  nares,  pharynx,  larynx,  and 
bronchial  tubes,  with  diminished  secretion,  followed  by  an 
increased  secretion  of  a  transparent  mucus,  afterward  becom- 
ing purulent,  the  mucous  membrane  pale  and  anemic.  Fatal 
cases  are  nearly  always  due  to  extension  and  exaggeration 
of  this  congestive  condition;  and  the  pathologic  conditions 
found  are  those  of  the  complications,  viz.,  bronchitis,  broncho- 
pneumonia, and  collapse  of  the  lung. 


WHOOPING    COUGH.  1 19 

Symptoms.— These  may  be  considered  in  three  stages:  catar- 
rhal, spasmodic,  and  terminal. 

Catarrhal  stage  originates  in  an  ordinary  naso-laryngo- 
bronchial  catarrh,  with  a  loose  cough.  There  is  frequently  a 
leukocytosis  (chiefly  of  lymphocytes).  Duration,  one  or  two 
weeks. 

Spasmodic  Stage.  The  cough  becomes  paroxysmal,  consist- 
ing of  a  succession  of  short,  rapid,  expiratory  efforts,  the  face 
becoming  red,  the  eyes  swollen  and  protruding,  the  body  bend- 
ing forward,  and  when  these  expiratory  efforts  have  exhausted 
the  breath,  they  are  followed  by  a  deep,  loud,  crowing  inspira- 
tion— the  whoop:  each  paroxysm  being  composed  of  several 
such  spells,  the  last  one  followed  by  the  expectoration  of  a 
small  amount  of  tough,  viscid  mucus.  The  attacks  of  cough 
may  be  so  severe  as  to  cause  vomiting,  and  if  the  vomiting  occur 
shortly  after  food  has  been  taken,  the  nutrition  of  the  patient 
will  suffer.  Profuse  epistaxis  is  not  infrequent.  Duration, 
about   four  weeks. 

Terminal  Stage.  The  paroxysms  recur  at  longer  intervals, 
are  of  shorter  duration  and  less  intensity,  the  catarrhal  symp- 
toms being  more  marked,  the  expectoration  freer.  Duration, 
one  or  two  weeks,   often  followed  by  the   "cough  of  habit." 

Complications. — The  most  common  complications  are  conges- 
tion of  the  lungs,  capillary  bronchitis,  pneumonia,  emphysema, 
and  collapse  of  the  lung.  Convulsions,  hydrocephalus,  and 
apoplexy  are  occasional  occurrences. 

Diagnosis. — This  is  certain  only  during  the  second  or  paroxys- 
mal stage,  the  "whoop"  of  which  is  especially  characteristic 
and  distinctive. 

Prognosis. — Depends  upon  the  age  and  strength  of  the 
patient,  the  severity  of  the  paroxysms,  and  the  presence  or 
absence  of  complications.  Ordinary  cases  are  favorable. 
Moderately  severe  attacks  during  infancy  are  followed  by 
cerebral  symptoms,  while  attacks  occurring  in  adults  are  fol- 
lowed by  chest  symptoms. 

Treatment. — There  is  no  specific  treatment.  The  disease 
is  self-limited.     The  symptoms  may  be  modified  by  treatment 


I20  WHOOPING   COUGH. 

and  complications  avoided.  Isolation  of  the  patient  and  dis- 
infection of  all  his  personal  articles  should  never  be  neglected. 
A  well- ventilated  room,  with  plenty  of  sunlight,  should  be  se- 
lected; but  the  patient  need  not  be  confined  to  bed.  On  nice 
days  he  should  be  allowed  in  the  open  air  as  much  as  possibly ; 
but  should  be  warmly  clad  so  as  not  to  catch  cold.  The  diet 
should  be  nutritious,  but  should  be  regulated  to  the  individual 
Inhalations  of  creosote  or  eucalyptol  are  very  valuable,  dropped 
upon  cotton  in  a  respirator,  or  vaporized  over  an  alcoholic  lamp, 
or  cloths  dipped  in  solutions  of  these  drugs  may  be  hung  about 
the  room. 

The  medicinal  treatment  includes  a  number  of  remedies. 
Quinin  sulphate,  in  full  doses,  and  chloral  alone  or  combined 
with  the  bromids,  belladonna  and  ipecac,  have  all  been  recom- 
mended; so  also  has  a  spray  of  sodium  bromid,  gr.  xx  (1.3  gm.), 
fluid  extract  of  belladonna,  nxii  (0.12  c.c),  and  water,  fSi 
(30  c.c).  Ammonium  bromid  may  also  be  used.  At  times 
benefit  may  be  obtained  from  the  administration  of  antipyrin, 
gr.  1/6  to  v  (o.oii  to  0.3  gm.),  acetanilid,  gr.  i  to  iii  (0.065 
to  0.2  gm.),  every  four  hours,  or  phenacetin,  gr.  i  to  ii  (0.065  ^^ 
0.13  gm.),  four  times  daily.  These  are  most  efficacious  when 
administered  in  expectorant  mixtures.  Holt  advises  the  use 
of  antipyrin  in  i  grain  (0.065  S''^-)  doses  every  three  hours  for 
a  child  six  months  old.  Terpin  hydrate,  gr.  i  to  v  (  0.065  "to 
0.3  gm.),  is  sometimes  valuable.  Belladonna  may  be  added 
to  any  of  the  remedies  named  with  advantage  or  the  tincture 
may  be  used  alone  in  doses  of  ttxv  to  x  (0.3  to  0.6  c.c.)  three 
times  daily,  gradually  ascending,  until  flushing  of  the  surface 
is  observed,  after  which  the  dose  is  continued  that  maintains 
the  flushing. 

Starr  recommends   the   following  for   a   child   of   one   year: 

I^.     Ext.  belladonnae gr.  j  .065  gm. 

Aluminis oss  2 .         gm. 

Syr.  zingiberis, 
Syr.  acaciae, 

Aquae. . , aa    f  5j       aa        30.  c.c. 

M.  S. — A  teaspoonful  foiir  tirn.es  in  the  twenty-four  hours. 


RHEUMATIC   FEVER.  121 

The  wearing  of  an  abdominal  belt  is  both  conafortable  and 
useful;  it  supports  the  abdominal  wall,  and  is  said  to  prevent 
vomiting. 

During  convalescence  tonics  should  be  administered.  Cod- 
liver  oil,  quinin,  iron,  etc.,  are  of  great  value  in  this  period 
in  preventing  pulmonary  sequels. 

RHEUMATIC  FEVER. 

Synonyms.— Acute  articular  rheumatism;  inflammatory  rheu- 
matism; acute  rheumatism. 

Definition. — An  acute  infectious  disease,  characterized  by 
fever,  inflammation  in  and  around  the  joints,  acid  sweats, 
and  a  great  tendency  to  inflammation  of  either  the  endocard- 
ium or  pericardium. 

Causes. — The  disease  is  believed  to  be  of  infectious  origin, 
but  no  specific  organism  has  as  yet  been  isolated.  The  tonsils 
are  very  often  the  portals  of  entry  for  the  infection.  Certain  pre- 
disposing factors  seem  necessary  for  the  production  of  the 
disease.  Among  these  may  be  mentioned  exposure  to  cold 
and  wet,  sudden  reductions  in  the  temperature,  lowered  vi- 
tality from  various  causes,  winter  and  spring  seasons,  heredity, 
infectious  fevers,  especially  scarlet  fever,  puerperium,  male 
sex,  and  previous  attacks.  The  affection  is  seldom  observed 
before  seven  or  after  fifty  years  of  age. 

Pathologic  Anatomy. — The  affected  joints  are  intensely  con- 
gested and  the  synovial  membrane  and  urrounding  ligamentous 
tissues  are  greatly  swollen.  The  cartilage  may  be  eroded. 
The  synovial  fluid  is  thinner  than  normal  and  of  a  reddish 
color,  containing  albumin,  some  gelatinous  coagula  of  fibrin, 
leukocytes,  but  no  pus  cells  or  organisms  in  simple  cases.  There 
is  an  increase  in  the  quantity  and  in  the  number  of  white  cor- 
puscles in  the  blood.  The  inflammatory  edema  of  the  joint 
and  adjacent  structures  gives  rise  to  considerable  visible  swell- 
ing and  by  its  stretching  of  the  parts  and  pressure  on  the  nerves 
induces,  in  all  probability,  the  pain.  The  joint  condition 
usually  ends  in  resolution.     The  complications  of  this  affection 


122 


RHEUMATIC   FEVER. 


possess  no  features  different  from  the  same  conditions  when 
occurring  independently. 

Symptoms. — Usually  the  onset  is  abrupt,  generally  at 
night,  with  a  chill  or  chilliness,  pain  and  stiffness  in  the  joints, 
loss  of  appetite,  and  at  times  nausea  and  vomiting,  followed 
by  fever,  the  temperature  soon  reaching  102°  to  104°  F.,  and 
in  rare  cases  108°  to  110°  F.     In  some  cases  it  is  preceded  by 


107 


106 
105 


^^104 


S  103 


•102 


gJQi 
%  100 


a    99 


97 


96 


Hi 


4  5 


ii 


i\ 


Q     7 


t 


m 


10 


11 


12 


13 


m 


14 


I 


l\ 


16 


!1 


17 


I 


18 


19 


l^il 


20 


21 


:-40 


-42 


-41 


—38 


38 


•37 


Fig.  19. — Clinical  chart  of  acute  articular  rheumatism  showing  renewal  of  the 
febrile  movement  consequent  upon  fresh  joint  involvement.  {From  Wilcox's  Fever 
Nursing.) 


slight  malaise,  vague  pains  in  the  joints,  and  tonsillitis.  After 
the  affection  has  begun,  there  are  profuse  acid  sweats,  great 
thirst,  constipation,  and  scanty,  high-colored,  acid  urine  con- 
taining an  excess  of  uric  acid  and  urates,  and  sometimes 
traces  of  albumin.  The  fever  continues  throughout  the  attack, 
often  with  marked  remissions.  Delirium  is  absent  except 
when  hyperpyrexia  is  present.  Sleep  is  prevented  by  the  pain 
and  the  profuse  perspiration.  The  strength  is  moderately 
well-preserved.      The    skin   is    covered   with   various   forms   of 


RHEUMATIC    FEVER.  I  23 

miliaria  or  prickly  heat  due  to  excessive  irritation  of  the  sweat- 
glands. 

The  local  phenomena  are  pain,  increased  by  motion  and 
pressure,  tenderness,  and  increased  heat,  swelling,  and  redness 
of  one  or  more  joints.  Swelling  is  most  apparent  in  those 
joints  not  covered  by  muscle  as  he  knee,  wrist,  elbow,  and  the 
ankle,  and  is  proportionate  to  the  acuteness  of  the  attack.  The 
inflammation  may  suddenly  cease  in  one  or  more  joints  and 
abruptly  appear  in  others. 

The  disease  is  extremely  irregula  as  regards  the  number  of 
joints  affected,  although  the  local  manifestations  are  controlled 
by  an  important  pathologic  law,  the  law  of  parallelism.  The 
affected  joints  are  either  on  one  side  of  the  body;  or  those  on 
both  sides  that  are  analogous,  as  the  knee  and  elbow,  wrist  and 
ankle,  hip  and  shoulder,  are  attacked  together.  This  migratory 
character  of  the  inflammation  is  especially  distinctive. 

In  some  cases  the  affection  is  unattended  by  articular  mani- 
festations. 

Complications. — The  most  common  complications  are  endo- 
carditis, pericarditis,  myocarditis,  cerebral  endarteritis,  pleurisy, 
peritonitis,  bronchitis,  pneumonia,  tonsillitis,  hyperpyrexia, 
erythema  nodosum,  urticaria,  and  purpura.  As  sequels  may 
be  mentioned  chorea,  acute  nephritis,  false  ankylosis,  chronic 
rheumatism,  and  exophthalmic  goitre. 

Duration. — The  duration  of  acute  rheumatism  is  governed 
entirely  by  the  presence  or  absence  of  complications.  Un- 
complicated cases  recover  in  from  thirteen  to  twenty-one  days, 
although  they  may  be  prolonged  to  five  or  six  weeks.  Relapses 
are  frequent. 

Diagnosis. — A  typical  case  cannot  be  mistaken  for  any  other 
disease,  but  cases  running  a  subacute  course  may  be  mistaken 
for  acute  rheumatoid  arthritis,  gonorrheal  rheumatism,  or 
pyemia. 

Acute  rkeumatoid  arthritis  attacks  one  joint  at  a  time  and  be- 
comes permanent,  has  slight,  if  any  fever,  and  no  sweats  or 
cardiac  lesions. 

Gonorrheal  rheumatism  is  associated  with  a  gleety  discharge. 


124  EHEUMATIC   FEVER. 

or  follows  the  sudden  cessation  of  an  acute  or  subacute  gonor- 
rhea, attacks  either  the  ankle  or  wrist  only,  is  slowly  influenced 
by  treatment,  and  lacks  the  febrile  phenomena. 

Pyemia  is  usually  manifested  in  a  single  joint  at  a  time,  and 
is  followed  by  all  the  symptoms  of  hectic  fever  and  suppuration. 

Prognosis. — Recovery  is  the  rule  in  uncomplicated  cases, 
the  mortality  being  about  3  per  cent.  When  death  occurs,  it 
usually  depends  upon  hyperpyrexia,  cardiac  complication,  or 
cerebral  endarteritis.     One  attack  predisposes  to  others. 

Treatment. — In  all  cases  the  patient  should  be  placed  at 
absolute  rest  in  bed.  He  should  wear  woolen  garments,  and 
blankets  (no  sheets)  should  constitute  the  bed  clothing,  care 
being  taken  to  protect  the  inflamed  joint  from  excessive 
weight  of  the  coverings.  The  diet  should  consist  of  easily- 
digested  substances,  preferably  milk.  The  free  use  of  water, 
particularly  the  alkaline  mineral  waters,  should  be  encouraged. 
In  strong  and  vigorous  patients  the  administration  of  salicylic 
acid  or  the  salicylates  in  large  and  frequently  repeated  doses 
is  of  great  benefit.  Sodium  salicylate,  ammonium  salicylate, 
strontium  salicylate,  salicin,  aspirin,  salol,  salophen,  or  oil  of 
wintergreen  may  be  used  and  pushed  to  the  point  of  tolerance. 
In  all  cases,  special  internal  treatment  should  be  preceded  by  a 
course  of  calomel  followed  by  a  saline  laxative. 

I^.     Acidi  salicylici Bss  15 .  gm. 

Liq.  ammonii  acetat.  .  .  .  f  5iv  120.  c.c. 

Spts.  aetheris  nitrosi f  5j  30.  c.c. 

Syr.  simplicis f  5j  30.  c.c. 

M.  S. — Tablespoonful  every  three  hours,  well  diluted. 


Or— 


I^.     Sodii  salicylat Sj  30 .  gm. 

Tinct.  cinchonse  comp. .  .   f  §iij  90.  c.c. 

Aq.  menth.  pip f  5iij  90 .  c.c. 

M.  S. — Dessertspoonful  every  three  or  four  hours  till  relief, 
when  the  interval  should  be  increased. 


RHEUMATIC   FEVER.-  1 25 

Or— 

I^.     Potassii  acetat 5j  30.  gm. 

Acid  salicylici Bss  15.  gm. 

S3nr.  limonis f  Sij  60 .  c.c. 

Aq.  menth.  pip f  §viij  240.  c.c. 

M.  S. — Tablespoonful  every  three  hours,  diluted. 

Usually  this  treatment  affords  rather  prompt  relief  but  if 
after  three  or  four  days'  trial  there  is  no  benefit  derived  from  it, 
alkaline  treatment  should  be  substituted.  This  consists  in 
the  administration  of  an  ounce  and  a  half  of  one  of  the  alka- 
line carbonates,  either  alone  or  combined  with  a  vegetable 
acid,  every  twenty-four  hours  until  the  urine  becomes  neutral 
or  alkaline  when  the  quantity  should  be  reduced  to  an  amount 
just  sufficient  to'  maintain  alkalinity.  The  following  prescrip- 
tions are  frequently  employed: 

I^.     Potassii  bicarbonatis ...  .    oij  8.  gm. 

Acid,  tartarici gr.  xxx  2  .  gm. 

M.  S. — Dissolve  in  a  glass  of  water  and  drink  effervescing 
every  three  hoiu^s. 

Or— 

I^.      Potass,  bicarb 5ij  8 .  gm. 

Succus  limonis f  5iv  15.  c.c. 

Aquas  chloroformi fSss  15.  c.c. 

M.  S. — In  water,  every  three  hours. 

After  the  acute  symptoms  have  subsided,  Basham's  mixture 
or  tincture  of  the  chlorid  of  iron,  tt^xx  (1.3  c.c.)  every  three 
hours,  should  be  administered.  In  pale,  feeble,  and  anemic 
patients   the   following   prescriptions   will   be   of   great   value: 

I^.      Strychninse  sulphat gr.  1/60  .001      gm. 

Tinct.  ferri  chlorid n^xv  to  xxx       i .  to  2  .   c.c. 

Liquor,  ammonii  acetat.    f§ss  15.  c.c. 

M.  S. — Every  four  hours,  in  a  glass  of  water. 


126 


RHEUMATIC    FEVER. 


Or— 


PV 


Sodii  salicylatis 5iv 

Glycerini f  oj 

Acidi  citrici gr.  x 

Ol.  gaultheriae f  3ss 

Mucil.  acacise f  Sss 

M.  Add  while  stirring 


15 

2 
15 


gm. 
c.c. 
6  gm. 
c.c. 
c.c. 


c.c. 


Tinct.  ferri  chlorid f  oiv  15 

Liq.  ammonii  citrat.      (B. 

P.) ad  f  5iv  ad   120 .     c.c. 

M.  S. — One  to  two  teaspoonfuls  every  two,  three,  or  four 
hours,  diluted  (S.  Solis-Cohen) .   • 

Subacute   attacks   and   lingering   cases   are   favorably   influ- 
enced by 

I^.      Lithii  salicylatis gr.  xv  to  xx   i .  to  1.3  gm. 

Syr.  zingiberis f  5j  4  .  c.c. 

Aq.  lauro-cerasi f  3j  4.  c.c. 

M.  S. — Every  four  hours. 

Or— 

I^.     Potassii  iodidi gr.  Ixxx 

Sodii  salicylatis 5iv 

Elix.  cinchonas f  §iss 

Infus.  gentianas f  §iss 

Aquae  destil f  o  j 

M.  S. — Dessertspoonful  every  three  or  four'  hours,  diluted. 

These   cases   also    do   well   with   the   use   of  salol,  gr.  v  to  x 
(0.3  to  0.6  gm.),  or  salipyrin  in  solution  every  four  hours. 


5 

3  gm 

15 

gm 

45 

c.c. 

45 

c.c. 

30 

c.c. 

I^.      Salipyrin 5iij 

Glycerini f  5iij 

Syr.  aurantii f  5 vj 

Aquas  destil q.  s.  ad  fSvj 

M.  S. — Tablespoonful,  well  diluted. 


12 
12 


gm. 
c.c. 


24.  c.c. 
ad  180 .  c.c. 


In  all  cases  quinin  sulphate,  gr.  xv  (i  gm.)  daily,  is  of  great 
value    especially    when    there    is    hyperpyrexia,    under    which 


LOBAR    PNEUMONIA.  1 27 

circumstance  it  should  be  administered  hypodermically  and 
accompanied  by  a  cold  bath  or  wet  pack.  The  pains  will  be 
relieved  to  some  extent  by  the  coal-tar  products,  but  the  best 
results  will  be  obtained  from  the  use  of  opium  in  some  form, 
or  atropin  sulphate,  gr.  1/80  (0.0008  gm.)  hypodermically, 
alone  or  combined  with  morphin. 

Local  Treatment. — Rest  of  the  affected  joint  is  essential. 
The  inflamed  parts  should  be  wrapped  in  cotton-wool  or  flan- 
nel saturated  with  lead-water  (2  parts  )  and  laudanum  (i  part), 
oil  of  gaultheria,  f5i  (4  c.c),  and  compound  soap  liniment, 
f5iii  (90  c.c),  or — 

I^.      Sodii  bicarbonatis 5ij  60.  gm. 

Tinct.  opii f  5 ss  1 5  .  c.c. 

Aquae  bul Oij  960  .  c.c. 

M.  S. — Use  locally  as  directed. 

The  application  of  blisters,  the  size  of  a  silver  dollar,  around 
the  joint  is  very  efficacious  in  relieving  the  pain  and  lessening 
the  inflammation.  If  the  joint  condition  tends  to  persist, 
equal  parts  of  mercurial  ointment  and  the  ointment  of  bel- 
ladonna will  be  found  of  great  value.  Baking  of  the  joint  in 
a  hot-air  apparatus  is  also  beneficial.  When  the  acute  symp- 
toms have  subsided  massage  may  be  employed. 

LOBAR  PNEUMONIA. 

•  Synonyms. — Croupous  pneumonia;  pneumonitis;  fibrinous 
pneumonia;  lung  fever. 

Definition. — An  acute,  infectious  inflammation,  involving 
the  vesicular  structure  of  the  lungs  rendering  the  alveoli  im- 
pervious to  air;  characterized  by  a  severe  chill,  headache,  fever, 
ending  by  crisis,  thoracic  pain,  dyspnea,  cough  rusty  sputum, 
and  great  prostration. 

Causes. — Lobar  pneumonia  is  an  infectious  di:ease  caused 
by  the  Diplococcus  pneumonicE  of  Fraenkel,  "  which  has  its  seat 
of  election  in,  and  produces  its  chief  effects  on,  the  lung."  The 
microorganism  is  found  in  the  sputum  and  in  the  lungs  in  the 


128  LOBAR   PNEUMONIA. 

majority  of  cases.  "  Occasionally  other  microorganisms  seem 
to  occasion  typical  fibrinous  pneumonia.  Among  these  are 
the  pneumococcus  of  Friedlander,  streptococci,  staphylococci, 
the  bacillus  of  typhoid  fever,  the  bacillus  of  influenza,  and  the 
bacillus  coli  communis.  In  some  cases  in  which  bacteria 
other  than  the  diplococcus  are  supposed  to  be  the  cause  there 
is  doubtless  mixed  infection,  but  it  must  be  accepted  at  the 
present  time  that  a  number  of  microorganisms  are  capable  of 
causing  the  disease "    (Stengel). 

All  ages  are  liable.  Males  are  more  frequently  affected  than 
females.  One  attack  predisposes  to  another.  Debilitating 
conditions  render  individuals  more  susceptible.  Alcoholism 
is  among  the  most  frequent  predisposing  factors.  The  affection 
is  most  frequent  in  winter,  at  times  occurring  epidemically, 
the  result  of  atmospheric  conditions,  and  exposure  to  draughts 
and  cold.  Gout,  rheumatism,  diabetes,  and  Bright's  disease 
may  also  be  causes. 

Pathologic  Anatomy. — The  most  frequent  seat  of  croupous 
pneumonia  is  the  lower  right  lobe ;  the  next  most  frequent  seat  is 
the  lower  left  lobe;  the  next,  the  upper  right  lobe,  although 
in  children  and  the  aged  this  lobe  is  affected  equally  as  often 
as  the  right  lower  lobe. 

The  changes  are:  I.  Hyperemia  (engorgement);  II.  Exuda- 
tion (red  hepatization) ;  III.  Resolution  (gray  hepatization) ; 
or  the  lung  may  undergo  purulent  transformation  with  the 
development  of  abscesses  (yellow  hepatization). 

I.  Stage  of  hyperemia,  or  congestion,  consists  in  distention 
of  the  vessel  of  the  alveoli  encroaching  on  the  cavity  of  the  air- 
vesicle;  the  lung  has  a  reddish-brown  color,  is  more  resistant, 
and  is  heavier,  sinking  somewhat  lower  in  water  than  a 
normal  lung,  and  having  a  slight  exudation  upon  the  vesicular 
surface.    The  same  changes  are  seen  in  the  adjacent  bronchioles. 

II.  Stage  of  exudation  consists  in  the  exudation  of  a  viscid, 
fibrinous  fluid,  mixed  with  white  and  red  corpuscles  and  blood 
rapidly  coagulating,  firmly  enclosing  the  corpuscles  and  com- 
pletely filling  the  alveoli.  When  the  exudation  and  co- 
agulation are  completed,  the  lung  is  red,  sinks  at  once  when 


LOBAR    PNEUMONIA.  I  29 

placed  in  water,  and  its  elasticity  is  destroyed.  When  cut, 
the  color,  density,  and  granular  appearance  so  closely  resemble 
the  cut  surface  of  a  section  of  the  liver  that  Laennec  termed 
the  condition  red  hepatization.  A  thin  section  shows  under 
the  microscope,  as  a  rule,  the  lancet-shaped  diplococcus  of 
Fraenkel,  as  well  as  staphylococci  and  streptococci. 

III.  Resolution,  or  gray  hepatization  follows  in  the  majority 
of  cases,  the  coagulated  albuminous  exudation  undergoing 
liquefaction  and  absorption,  the  cellular  element  undergoing 
a  fatty  degeneration,  the  greater  part  being  absorbed,  the 
remainder  expelled  during  acts  of  expectoration,  the  alveoli 
returning  to  their  normal  condition,  as  to  capacity,  function, 
and  elasticity.  The  consolidated  area  softens  and  becomes 
mottled  gray  in  appearance. 

If  resolution  be  retarded  and  portions  of  the  coagulated  exuda- 
tion undergo  purulent  transformation  changing  from  a  yellow- 
ish to  a  greenish-yellow  color  {yellow  hepatization),  pus  cells 
are  rapidly  formed,  the  part  becoming  a  granular,  fatty  mass. 
The  portions  of  the  lung  not  undergoing  this  purulent  trans- 
formation retain  the  reddish  color  with  intermixed  yellowish 
patches.  The  purulent  contents  may  be  ejected  in  part,  the 
remainder  undergoing  fatty  degeneration  and  finally  absorption. 

Abscess  of  the  lung  may  result  from  the  lung  structure  becom- 
ing involved  in  the  purulent  disintegration.  Abscesses  may 
be  solitary  or  in  great  numbers,  which  by  disintegration  of 
intervening  structure  coalesce,  and  form  one  or  more  large 
abscesses;  these  abscesses  either  terminate  fatally  or  open  into 
the  pleural  cavity,  causing  empyema  and  exhaustion,  or  open 
into  the  bronchi  and  are  expectorated,  or  an  interstitial  pneu- 
monia is  developed  and  the  abscess  is  encapsulated  in  a  firm 
cicatricial  tissue. 

Gangrene  of  the  lungs  may  result  from  blocking  up  of  the 
bronchial  or  pulmonary  arteries  by  coagula  during  any  stage  of 
the  disease. 

The  uninflamed  portions  of  the  lungs  are  hyperemic  and 
their  functional  activity  is  increased. 

Death  sometimes  results  from  a  general  edema  of  the  un- 

9 


130  '  LOBAR   PNEUMONIA. 

affected    lung,    such    cases    being    often    erroneously    termed 
^^ double  pneumonia." 

If  infiammation  of  the  pleura  be  associated  with  a  pneumonia, 
the  so-called  pleuropneumonia,  the  changes  in  the  pulmonary 
pleura  are  characteristic.  "  An  uneven,  thin,  downy -looking 
layer,  of  plastic  exudation  covers  its  surface.  This  plastic 
layer  may  conceal  the  liver-brown  color  of  the  pneumonic 
lung.  As  the  third  stage  is  reached,  the  opposing  surfaces  of 
the  pleura  may  become  agglutinated.  The  pleuritic  changes 
follow  very  closely  those  which  occur  within  the  lung.  The 
cells  in  the  pleuritic  exudation  are  mainly  pus.  The  pleuritic 
membrane  is  opaque,  congested,  and  ecchymotic.  It  may 
become  so  thick  as  to  give  a  dull  note  on  percussion,  after 
resolution  is  reached." 

Duration  of  stages:  stage  of  congestion,  from  one  to  three 
days;  stage  of  exttdation,  from  three  to  seven  days;  stage  of 
resolution,  from  one  to  three  weeks. 

In  severe  cases,  or  in  the  very  young,  the  aged,  or  the  de- 
pressed, the  stage  of  red  hepatization  may  be  fully  developed 
within  forty-eight  hours. 

Endocarditis,  either  simple  or  malignant,  is  a  common  accom- 
paniment. Pericarditis  is  frequent.  The  spleen  is  usually 
enlarged  and  soft. 

Symptoms. — The  affection  begins  with  a  severe  and  usually 
protracted  chill  (in  children  often  convulsions,  and  in  adults 
sometimes  vomiting),  followed  by  a  rapid  rise  of  temperature, 
103°  to  104°  F.,  a  strong,  full,  but  rapid  pulse,  soon  showing 
evidence  of  embarrassed  cardiac  action  from  obstruction  of  the 
pulmonary  circulation.  There  are  also  present  either  a  dull 
or  sharp  pain  near  the  nipple,  aggravated  by  pressure,  breath- 
ing, or  coughing;  shortness  of  breath,  the  inspiration  short 
and  superficial,  the  expiration  accompanied  by  a  moan  or 
grunt,  the  number  of  respirations  increasing  to  40,  50,  or  more 
a  minute,  causing  interrupted  speech;  disturbance  of  the 
ratio  between  pulse  and  respiration;  and  cough,  at  first  short, 
ringing,  and  harsh,  followed  by  a  scanty,  frothy,  mucoid  ex- 
pectoration,    The  sputum  soon  becomes  transparent,   viscid, 


LOBAR   PNEUMONIA. 


131 


and  tenacious,  changing  about  the  second  day  to  the  familiar 
rusty  sputum.  The  quantity  is  increased  and  a  yellow  color 
is  assumed  as  the  disease  advances.  In  rare  instances,  cases 
occur  in  which  the  bloody  or  blood-streaked  sputum  continues 


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Fig.   20 — Clinical  chart  of  acute  pneumonia  showing  pulse   and  respiration.      De- 
fervescence upon  the  seventh  day  of  the  disease.      {From  Wilcox's  Fever  Nursing.) 

throughout  the  disease.  Microscopic  examination  of  the 
sputum  in  simple  cases  shows  it  to  contain  red  blood  cells, 
blood  pigment,  pus  cells,  the  characteristic  diplococci  and 
various  other  microorganisms. 

From  the  very  onset  of  the  disease,  the  prostration  is  of  the 


132  LOBAR   PNEUMONIA. 

most  pronounced  character.  The  countenance  is  flushed,  and 
especially  over  the  malar  bones  there  is  a  well-defined  ma- 
hogany blush.  The  lips  are  more  or  less  blue  and  herpes  may 
be  observed  upon  them.  Epistaxis,  headache,  sleeplessness, 
and  gastric  disturbances  are  common.  The  tongue  is  coated, 
the  appetite  is  impaired,  and  there  is  constipation.  Delirium 
is  sometimes  present,  and  when  occurring  early  is  a  grave  sign. 
The  urine  is  small  in  amount,  highly  colored,  deficient  in 
chlorids,  and  often  slightly  albuminous.  The  blood  shows 
evidences  of  leukocytosis. 

The  fever  usually  reaches  its  maximum  within  twenty-four 
hours  and  continues  high,  with  diurnal  remissions,  until  either 
the  fifth,  seventh,  ninth,  or  eleventh  day,  when  a  crisis  occurs, 
and  within  twenty-four  hours  all  the  symptoms  are  decidedly 
lessened,  the  fever  absent,  and  convalescence  is  established, 
followed  by  rapid  recovery.  Occasionally,  the  termination 
is  by  lysis. 

Physical  Signs. — Inspection  reveals  during  the  first  stage 
deficient  movement  of  the  affected  side,  due  to  pain.  The 
apex-beat  is  normal  in  situation,  and  the  interspaces  do  not 
bulge.  In  the  second  stage  the  healthy  side  rises  normally, 
the  affected  side  lagging  behind.  If  both  lower  lobes  are 
impervious  to  air,  the  diaphragm  cannot  descend  and  the 
epigastrium  does  not  project  during  inspiration,  the  breathing 
being  conducted  by  the  upper  part  of  the  chest  (superior  costal 
respiration) . 

Palpation  during  the  first  stage  shows  the  vocal  fremitus  to 
be  more  distinct  than  normal,  especially  over  the  diseased 
portions.  In  the  second  stage,  the  vocal  fremitus  is  markedly 
exaggerated,  except  in  those  rare  instances  of  occlusion  of  the 
bronchi  by  secretion.  The  cardiac  impulse  is  felt  in  the 
normal  position. 

Percussion. — In  the  first  stage,  the  percussion  note  is  slightly 
impaired  at  times,  having  a  hollow  or  tympanitic  quality.  In 
the  second  stage,  there  is  dullness  over  the  affected  parts,  with 
an  increased  sense  of  resistance.  Over  unaffected  adjoining 
areas,  the  resonance  is  increased  ( Skoda 's  resonance). 


LOBAR   PNEUMONIA. 


133 


Auscultation. — In  the  first  stage  there  is  heard  over  the  affected 
part  a  feeble  vesicular  murmur,  associated  with  the  true 
vesicular  or  crepitant  (crackling)  rale,  heard  at  the  end  of  inspi- 
ration only.  In  the  second  stage  there  is  harsh,  high-pitched, 
bronchial  respiration,  at  times  resembling  a  to-and-fro  metallic 
sound,  except  in  those  rare  instances  in  which  the  bronchi  are 
more  or  less  filled  with  secretion.  Bronchophony,  or  distinctly 
transmitted  voice,  is  present  and  at  times  pectoriloquy, 
or  distinct  transmission  of  articulated  sounds,  may  be  heard. 
In  the  third  stage,  the  breathing  changes  from  bronchial  to 
bronchovesicular  and  the  crepitant  rale  (crepitatio  redux) 
returns.  As  resolution  proceeds,  the  breath  sounds  are  as- 
sociated with  large  and  small  moist  and  bubbling  rales.  Ac- 
cording to  Da  Costa,  the  physical  signs,  symptoms,  and  mor- 
bid phenomena  of  this  malady  correspond  usually  in  the 
following  manner: 


II. 


Stage  of  engorgement 
and  beginning  exu- 
dation. 

Stage  of  solidification 
of  lung  tissue  (red 
hepatization). 


III.   Stage      of       softening 
(gray  hepatization) . 


Crepitant  rale ;  slight  per- 
cussion dullness. 


Percussion  dullness;  bron- 
chial respiration;  bron- 
chophony. 


The  same  physical  signs 
as  in  the  second  stage, 
unless  large  abscesses 
have  formed. 


Cough;  beginning  dysp- 
nea and  rapidly  de- 
veloped fever  heat. 

Rusty-colored  sputum ; 
dyspnea ;  cough ;  high 
fever  with  marked 
evening  exacerbations 
and  morning  remis- 
sions. 

Chills;  prostration,  etc.; 
piurulent  or  brownish 
sputum ;  generally  high 
temperature. 


Clinical  Varieties. — Typhoid  pneumonia  is  a  term  applied  to 
those  cases  which  are  accompanied  by  signs  of  extreme  prostra- 
tion, delirium,  tremor,  very  high  temperature,  and  profuse  and 
prolonged  exudation ;  they  may  also  terminate  by  a  crisis. 

Bilious  pneumonia  occurs  in  cases  accompanied  by  congestion 
of  the  liver  or  bile  ducts;  the  result  of  venous  stasis  from  pul- 
monary obstruction  or  from  an  accompanying  acute  catarrhal 
jaundice.  In  malarial  districts  pneumonia  and  malaria  are 
often  associated,  when  jaundice  more  or  less  pronounced  occurs. 
Such  cases  are  termed  malarial  or  inter m^ittent  pneumonia. 

Alcoholic,   or  pneumonia  of  the  intemperate,   has  one   very 


134  LOBAR   PNEUMONIA. 

characteristic  symptom,  viz.,  early  delirium.  In  pneumonia 
generally  the  mind  is  clear,  even  when  all  the  conditions  are 
unfavorable.  Pneumonia  of  the  intemperate  may  begin  with 
symptoms  closely  resembling  an  attack  of  delirium  tremens, 
cough,  expectoration,  and  pain  being  very  slight,  or  even 
absent. 

Pneumonia  in  the  aged  or  the  insane  may  be  latent,  coming 
on  without  chill  or  pain  and  with  only  a  slight  fever;  the  cough 
and  expectoration  are  slight,  physical  signs  ill  defined  and 
changeable,  and  the  constitutional  symptoms  out  of  all  propor- 
tion to  the  amount  of.  lung  involved. 

A  pyretic  pneumonia  is  that  which  lacks  fever,  and  is  the 
result  of  exhaustion  and  the  depressing  effect  of  the  infecting 
agent  on  the  nervous  system.  It  may  occur  as  the  result  of 
embolism, 

Aspiration  pneumonia  is  due  to  the  aspiration  of  fluids  of 
any  kind,  the  disease  being  really  of  mechanical  origin. 

Tratimatic  pneumonia  is  the  variety  resulting  from  severe 
contusions  of  the  chest,  the  trauma  predisposing  to  the  disease 
by  mechanical  injury  of  the  lung,  the  diplococcus  finding  suit- 
able nidus  at  the  site  of  injury. 

Pneunwnia  in  children  is  marked  by  nervous  phenomena. 
Convulsions  often  usher  in  the  attack;  and  headache,  delirium, 
coma,  and  hyperpyrexia  are  prominent  symptoms. 

In  addition  to  the  above,  pneumonia  is  said  to  be:  apical, 
when  the  apex  of  the  lung  is  affected;  basal,  when  at  the  base 
of  the  lung;  double,  when  both  lungs  are  involved;  creeping  or 
migratory,  when  different  parts  of  the  lung  or  lungs  are  succes- 
sively involved;  central,  when  the  affection  begins  at  the  center 
of  a  lobe,  and  spreads  to  the  surface,  and  often  gives  no  physical 
signs;  latent,  when  it  is  present,  but  not  discovered  or  even  sus- 
pected; massive,  when  a  large  portion  of  the  lung  or  a  whole 
lung  is  involved;  terminal,  when  it  occurs  in  the  final  stage  of 
many  diseases  (it  is  often  bronchopneumonia) ;  the  terms  post- 
operative and  ether  pneumonia  explain  themselves. 

Terminations. — Asthenic  cases  recover  within  two  weeks. 
When  purulent  infiltration  supervenes,   the  disease  pursues  a 


LOBAR    PNEUMONIA.  I35 

tedious  course  of  several  weeks'  duration,  with  a  low  exhaustive 
fever. 

If  purulent  infiltration  follow  the  stage  of  red  hepatization, 
instead  of  the  crisis,  symptoms  of  exhaustion  occur,  with  pro- 
fuse purulent  expectoration,  high  temperature,  severe  sweats, 
the  tongue  brown  and  dry,  sordes  collecting  on  the  gums,  low 
delirium,  feeble  pulse,  rapid,  rattling  breathing,  the  recovery 
slow,  and  convalescence  tedious. 

If  death  occur  during  the  first  or  second  stages,  it  is  usually 
the  result  of  a  collateral  edema  of  the  uninflamed  lung,  abscess, 
gangrene,  phthisis,  or  profound  toxemia,  or  cardiac  failure  and 
impaired  nerve-force. 

If  abscesses  occur,  there  are  exhausting  sweats,  frequent 
cough,  with  a  large  amount  of  yellowish-gray,  at  times  blood- 
streaked,  expectoration. 

Gangrene  of  the  lungs  is  a  rare  termination;  it  is  associated 
with  symptoms  of  collapse,  the  expectoration  of  a  blackish, 
fetid  character,  with  the  physical  signs  of  a  pulmonary  cavity. 

Fibroid  induration  or  pulmonic  cirrhosis  and  phthisis  are 
occasional  terminations. 

Complications. — Acvite  pleuritis  is  a  frequent  complication  of 
croupous  pneumonia,  occurring  as  often  as  from  10  to  25  per 
cent,  of  cases.  The  more  acute  localized  pain,  the  greater 
embarrassment  of  respiration,  and  the  usual  physical  signs  of 
effusion  are  the  evidences  of  a  pleuropneumonia. 

Endocarditis  is  a  common  complication,  showing  irregular 
but  protracted  temperature  record,  with. chills  and  sweats  and 
great  embarrassment  of  the  respiration. 

Meningitis  and  capillary  bronchitis  are  rare  but  dangerous 
complications.  Pericarditis,  rheumatism,  and  gout  are  rare 
complications. 

Diagnosis. — Edema  of  the  lungs  may  be  confounded  with  the 
first  stage  of  pneumonia,  but  the  subsequent  history,  its  pres- 
ence on  both  sides,  and  the  waterish  expectoration  and  absence 
of  chill  and  pain  and  the  physical  signs  of  pneumonia  soon 
determine  the  diagnosis. 

Pleurisy  is  more  often  confounded  with  pneumonia  than  any 


136  LOBAR   PNEUMONIA. 

other  disease,  the  points  of  distinction  between  which  will  be 
pointed  out  when  discussing  that  affection. 

Typhoid  fever,  when  accompanied  by  hypostatic  congestion 
of  the  lungs,  may  be  mistaken  for  pneumonia;  the  history, 
mode  of  onset,  temperature  record,  Widal  reaction,  etc.,  will  aid 
in  making  the  correct  diagnosis.  Hypostatic  congestion  occurs 
late  in  typhoid,  while  pulmgnary  congestion  is  the  earliest 
manifestation  in  pneumonia. 

Acute  phthisis  may  resemble  the  affection  closely,  and  is 
only  differentiated  with  certainty  by  finding  the  tubercle 
bacillus  in  the  sputum. 

In  Bright' s  disease,  valvular  heart  disease,  diabetes,  and 
alcoholism,  the  condition  of  the  lungs  should  be  ascertained 
at  frequent  intervals,  as  these  affections  are  prone  to  be  com- 
plicated with  pneumonia. 

Prognosis. — This  depends  largely  upon  the  extent  of  the  in- 
flammation. Double  pneumonia  is  especially  grave.  The 
disease  is  uncertain;  the  mortality  ranging  from  20  to  40  per 
cent.  In  young  adults  of  temperate  habits,  the  outlook  is, 
as  a  rule,  good,  while  in  the  aged  and  intemperate  the  prognosis 
is  bad.  Pneumonia  in  drunkards  almost  invariably  terminates 
fatally.  Typhoid  pneumonia,  pneumonia  in  the  insane, 
bilious  pneumonia  so-called,  purulent  infiltration,  abscesses  of 
the  lung,  and  gangrene,  all  have  a  grave  outlook.  Heart  or 
kidney  disease  influence  pneumonia  unfavorably.  Cases  in 
which  the  temperature  is  subnormal  or  is  extremely  high  are  also 
very  grave  and  seldom  recover.  A  very  rapid  pulse,  severe 
nervous  symptoms,  and  the  absence  of  leukocytosis  are  unfavor- 
able symptoms.  Meningitis  in  the  course  of  pneumonia  usually 
terminates  fatally. 

Treatment. — If  pneumonia  be  regarded  as  a  constitutional 
malady  with  a  local  lesion,  then  the  consolidated  lung  no  more 
calls  for  treatment  than  does  the  intestinal  ulcer  of  typhoid 
fever,  and  the  general  condition  of  the  patient  is  to  govern  in 
the  management  and  not  the  local  changes  in  the  thorax. 
A  simple  pneumonia  attacking  persons  previously  in  good 
health  requires  no  more  active  treatment  than  any  of  the  so- 


LOBAR    PNEUMONIA.  1 37 

called  self-limited  diseases,  provided  only  that  the  extent  of 
the  disease  be  moderate,  and  there  be  no  complication. 

The  ''open-air  treatment''  is  the  latest  and  best  in  the  thera- 
peutics of  pneumonia.  The  patient  must  be  well  wrapped  up 
and  protected,  and  then  allowed  all  the  fresh  air  that  is  avail- 
able ;  it  is  beneficial  in  every  way,  modifying  most  of  the  symp- 
toms and  aiding  all  forms  of  medication.  If  patients  were 
allowed  more  fresh  air  at  the  beginning  of  the  disease,  there 
would  be  less  call  for  oxygen  at  the  end;  fresh  air  bears  about 
the  same  relation  to  canned  oxygen  that  good  porterhouse  steak 
does  to  embalmed  beef. 

The  patient  should  be  placed  at  rest  in  bed  in  a  moderately 
heated  and  well  ventilated  room,  and  protected  from  all 
draughts. 

The  diet  must  be  of  the  most  nutritious  but  easily  digestible 
character,  and  given  at  periods  of  every  three  hours,  watching 
that  the  food  is  assimilated.  A  distended  stomach  and  ab- 
domen are  dangerous.  Strong  black  coffee  throughout  the 
disease  is  valuable.  Liquid  or  semisolid  substances,  such  as 
milk,  broth,  eggs,  etc.,  are  especially  serviceable.  A  cotton 
jacket  should  be  applied  to  the  chest,  unless  contraindicated 
by  other  local  treatment. 

The  much-discussed  question  of  venesect  on  is  now  a  settled 
problem  in  the  affection;  if  we  bleed,  it  is  ''not  because  of  pneu- 
monia, hut  in  spite  of  pneumonia.''  Called  to  a  patient  in  the 
first  stage  or  early  in  the  second  stage,  who  has  been  vigorous 
and  otherwise  healthy,  with  a  high  temperature,  105°  F.  or 
more,  with  frequent  pulse,  120  beats  or  more,  or  a  slow,  full 
pulse  showing  cardiac  oppression,  flushed  surface,  and  marked 
dyspnea,  a  copious  bleeding  is  indicated,  and  the  same  may  be 
said  when  symptoms  of  collateral  edema  threaten ;  this  bleeding 
is  for  the  symptoms  and  not  for  the  disease  per  se. 

There  is  no  remedy  which  can  exert  a  favorable  influence 
upon  the  pneumonic  process.  Many  cases  recover  without, 
and  many  cases  in  spite  of,  treatment.  When  treatment  is 
instituted,  be  guided  by  the  fact  that  you  are  not  to  treat  pneu- 
monia, but  a  patient  with  a  pneumonia. 


138  LOBAR    PNEUMONIA 

At  the  onset,  if  venesection  is  not  indicated,  relief  of  the  pain 
may  follow  the  use  of  dry  or  wet  cups.  If  the  tongue  be 
coated  and  the  gastrointestinal  canal  deranged,  a  calomel 
purge  is  indicated. 

I^.      Hydrargyri  chloridi  mitis  gr.  ij  .13     gm. 

Sodii  bicarb gi"-  iv  .26     gm. 

Pulv.  ipecac gr.  j  .065  gm. 

M.     Ft.  chart.  No.  iv. 

S. — One  every  two  hours,  followed  in  two  hours  after  last 
powder  by  mild  saline. 

Action  on  the  skin  and  kidneys  by  refrigerant  mixtures  or 
small  doses  of  Dover's  powder  is  valuable.  The  administra- 
tion of  the  arterial  sedatives,  aconite  and  veratrum  viride,  is 
recommended  by  Drs.  Da  Costa  and  H.  C.  Wood.  In  pneu- 
monia of  children,  the  use  of  small,  frequently  repeated  doses 
of  tincture  of  aconite,  in  the  early  stage,  is  most  useful. 

Poultices  are  of  slight  value,  but  home-made  mustard 
plasters,  weakened  with  flour,  may  be  used  in  all  stages.  If 
the  heart  be  weak  from  the  onset,  either  of  the  following  are 
valuable:  digitalis,  citrated  caiTein,  nitroglycerin,  spartein,  or 
strychnin.  Indeed,  it  seems  a  good  practice  to  administer 
strychnin  in  full  doses  from  the  onset.  Quinin  sulphate,  gr. 
ij  to  V  (0.13  to  0.3  gm.)  every  three  or  four  hours,  is  always 
valuable. 

Second  Stage.  During  this  period  the  indications  are  to 
maintain  the  heart's  action  and  to  lessen  the  fever.  Cardiac 
failure  being  one  of  the  most  common  causes  of  death  in  pneu- 
monia, it  is  highly  important  to  sustain  the  heart  from  the 
very  beginning.  Strychnin  sulphate,  gr.  1/32  to  1/20  (0.002 
to  0.003  g^^-).  administered  every  three  hours,  by  the  mouth  or 
hypodermically,  citrated  caffein,  gr.  ii  to  v  (0.13  to  0.3  gm.), 
every  four  hours,  or  tincture  of  strophanthus,  rr^v  to  x  (0.3 
to  0.6  c.c),  every  three  hours,  are  valuable  cardiac  tonics  in 
pneumonia.  The  employment  of  digitalis  and  nitroglycerin 
depends  upon  the  condition  of  the  pulse.  If  the  tension  is 
low,    the   result   of   relaxation   of   the   peripheral   blood-vessels 


LOBAR   PNEUMONIA.  1 39 

— vasomotor  paralysis — digitalis  in  full  doses ~is  indicated;  but 
if  the  tension  is  high,  with  embarrassed  right  heart,  nitroglycerin, 
combined  with  aromatic  spirits  of  ammonia,  should  be  ad- 
ministered every  hour  or  two.  Alcoholic  stimulants  judiciously 
employed  are  most  efficient  means  of  preventing  or  overcom- 
ing the  cardiac  failure.  The  amount  can  only  be  determined 
by  a  careful  study  of  each  case,  as  a  few  ounces  in  the  twenty- 
four  hours  may  answer  in  one,  while  another  may  require  8  or 
10  ounces.  It  is  well  to  begin  with  small  doses,  increasing  or 
decreasing  as  its  effects  are  good  or  bad.  The  indicator  of  the 
heart's  condition  is  the  pulse.  In  the  aged,  the  feeble,  or  in 
those  accustomed  to  the  use  of  alcohol,  stimulation  is  indicated 
from  the  onset.  Other  indications  would  be  a  frequent, 
feeble,  irregular,  or  intermitting  pulse;  a  dicrotic  pulse;  delirium, 
muscular  tremor,  and  subsultus;  immediately  following  crisis, 
and  the  period  of  collapse.  Hypodermoclysis  of  normal  hot 
salt  solution  is  also  recommended.  When  collapse  threatens, 
camphorated  oil    hypodermically  is  of  great  service. 

Reduction  of  temperature  is  very  necessary  in  many  cases. 
If  the  fever  is  under  103°  F.,  cool  sponging  with  alcohol  and 
water,  or  water  alone,  is  sufficient.  If  the  temperature  is  above 
104°  F.,  antifebrin,  gr.  v  (0.3  gm.),  may  be  used  every  three 
hours  until  a  reduction  occurs.  Strychnin  sulphate,  or  ci- 
trated  caffein  may  be  added  to  each  dose.  Phenacetin  or 
acetanilid  are  also  valuable  and  considered  less  depressing, 
but  it  is  to  be  remembered  that  a  temperature  under  104"  F. 
is  as  normal  to  pneumonia  as  the  dyspnea  or  the  rusty  sputum, 
and  consequently  antipyretic  drugs  should  be  used  with  caution. 
The  use  of  the  cold  pack  or  cold  baths  for  reducing  the  tem- 
perature in  acute  pneumonia  has  not  given  the  success  expected. 

The  use  of  ice-bags  to  the  chest  has  been  strongly  advocated, 
and  beneficial  results  seem  to  follow. 

For  dyspnea  and  pain  the  cardiac  stimulants  should  be  con- 
tinued, and  in  addition  morphin  sulphate  should  be  administered 
hypodermically  as  the  occasion  requires.  Counter-irritation 
to  the  chest  will  also  relieve  the  pain.  The  inhalation  of  oxy- 
gen will  lessen  the  shortness  of  breath,   but  too  much  should 


140  LOBAR   PNEUMONIA. 

not  be  expected  from  this  remedy,  as  there  is  some  additional 
factor  besides  the  mechanical  one  of  consolidation  of  the  lung 
producing  the  dyspnea,  for  the  consolidation  is  just  as  marked 
immediately  after  the  crisis,  while  the  dyspnea  is  wonderfully 
relieved. 

While  the  forms  of  treatment  already  given  will  in  great 
measure  lessen  the  cough,  there  are  times  when  something 
additional  is  necessary  to  relieve  this  distressing  symptom. 
In  such  cases,  morphin,  codein,  heroin,  Dover's  powder,  citrate 
of  potassium,  ammonium  chlorid,  and  ammonium  carbonate, 
are  especially  beneficial. 

Sleeplessness  and  delirium  are  best  overcome  by  sulphonal, 
trional,  chloralamid,  chloral,  or  the  bromids.  The  combina- 
tion of  strychnin  and  trional  is  of  value.  Opium  is  sometimes 
necessary,  but  is  contra-indicated  in  the  presence  of  pulmonary 
edema  or  dyspnea. 

Third  Stage.  The  treatment  is  a  continuation  of  that  of 
the  second  stage,  with  the  addition  of  the  following  valu- 
able combination: 

I^.     Ammonii  chloridi gr.  v  to  x  .  3  to  .  6      gm. 

Strychninae  sulphat gr.  1/24  .003  gm. 

Aquae  chloroformi f  5  j  4 .  c.c. 

Syr.  prun.  virg f  5iij  12.  c.c. 

M.  S. — Every  three  hours,  diluted. 

In  all  cases,  the  condition  of  the  heart  should  be  carefully 
watched  and  the  medication  and  dosage  should  be  guided 
largely  by  its  action.  This  is  particularly  true  in  the  asthenic 
varieties  of  the  disease. 

During  convalescence,  the  diet  should  be  highly  nutritious, 
and  iron,  quinin,  strychnin,  wine,  malt  liquors,  cod-liver  oil, 
etc.,  should  be  administered.  If  consolidation  shows  any 
tendency  to  linger,  blisters  should  be  applied  locally  and  the 
iodids  administered  internally. 

The  serum  treatment  and  the  antiseptic  treatment,  so-called, 
are  as  yet  not  generally  accepted  and  are  still  under  consid- 
eration. 


PULMONARY   TUBERCULOSIS.  I4I 

TUBERCULOSIS. 

Tuberculosis  is  an  infectious  disease  caused  by  the  invasion 
of  the  tissues  by  the  tubercle  bacillus.  It  is  characterized  by 
the  formation  "of  tubercles"  which  have  a  tendency  to  unite 
and  undergo  degenerative  changes  (caseous,  fibroid,  or  other). 
The  lungs  are  most  frequently  attacked,  but  the  pleuras, 
peritoneum,  meninges,  intestinal  tract,  bones,  and  generative 
and  other  organs  may  also  be  the  seat  of  the  disease. 

Tuberculosis  is  not,  as  a  rule,  hereditary;  but  a  predisposition 
to  the  disease  may  be  inherited,  and  lowered  resisting  power 
to  the  attacks  of  the  bacillus  may  also  be  inherited.  The 
modes  of  infection  are:  (i)  By  inhalation:  (2)  by  ingestion  of 
tuberculous  material;  (3)  by  the  tonsils  and  lymphatics;  (4)  by 
inoculation  (this  generally  is  purely  local).  For  description  of 
the  tubercle,  and  the  tubercle  bacillus,  see  pages  149  and  504. 

PULMONARY  TUBERCULOSIS. 

Synonyms. — Phthisis  pulmonalis;  phthisis;  consumption; 
pneumonic  phthisis;  tubercular  phthisis. 

Definition. — An  infective  disease,  caused  by  the  Bacillus 
tuberculosis ,  the  lesions  of  which  are  characterized  by  nodtilar 
bodies  called  tubercles  or  diffused  infiltrations  of  tuberculous 
tissue,  which  undergo  caseation  or  sclerosis,  and  may  finally 
ulcerate,  or,  in  some  situations,  calcify  (Osier). 

Clinical  Varieties. — I.  Acute  miliary  tuberculosis;  II.  Pneu- 
monic phthisis;    III.  Tubercular  phthisis;  IV.  Fibroid  phthisis. 

Cause. — It  is  now  generally  accepted  that  all  varieties  of 
pulmonary  consumption  are  due  to  the  active  presence  of  the 
Bacillus  tuberculosis,  discovered  by  Koch  in  1882.  The  lung- 
tissue  must  be  in  a  receptive  state,  as  the  bacilli  may  be  pres- 
ent in  the  respiratory  tract  without  the  development  of  the 
disease. 

Any  condition  that  lowers  the  tone  of  the  general  system 
renders  the  tissues  susceptible  to  the  changes  produced  by  the 


142  ACUTE    MILIARY    TUBERCULOSIS. 

tubercle  bacilli.     These  will  be  enumerated  in  speaking  of  the 
clinical  varieties  of  the  disease. 

ACUTE  MILIARY  TUBERCULOSIS. 

Syonyms. — Acute   phthisis;   galloping  consumption. 

Definition. — An  acute  infectious  febrile  affection,  due  to  the 
rapid  eruption  in  various  parts  of  the  body,  but  especially  in 
the  lungs,  of  miliary  tubercles;  characterized  by  high  fever, 
rapid  pulse,  hurried  respiration,  pains  in  the  chest,  cough, 
profuse  expectoration,  and  rapid  prostration. 

Causes. — In  the  majority  of  cases  it  is  the  result  of  an  auto- 
infection,  arising  from  either  an  active  or  latent  tuberculous 
focus.  Cases  develop  in  which  no  cause  can  be  assigned.  It 
often  follows  measles,  whooping  cough,  variola,  and  influenza. 
The  disease  is  most  frequent  between  puberty  and  middle  life. 

"  That  the  gray  granulation  be  deposited  throughout  the 
body  under  the  influence  of  certain  conditions  of  irritation,  it 
is  necessary  that  a  peculiar  vulnerability  of  the  constitution 
exist — in  other  words,   that  it  be  of  the  scrofulous  type." 

Pathologic  Anatomy. — "  The  gray  granulation,  or  miliary 
tubercle  consists  of  a  fine  reticulation  of  fibers,  with  a  mass 
of  epithelioid  cells  and  granules,  and  often  having  a  giant  cell 
for  its  center."  The  deposit  is  generally  over  both  lungs  and 
the  bronchial  tubes,  and  is  followed  by  hyperemia,  increase  of 
secretion,  having  a  viscid  and  adhesive  character,  and  the  de- 
struction of  all  the  tissue  with  which  it  comes  in  contact. 

Deposits  also  take  place  in  the  brain,  pleura,  intestines, 
peritoneum,  and  kidneys. 

Clinical  Forms. — General  or  typhoid,  pulmonary,  and  cerebral. 

Symptoms. — The  typhoid  variety  of  the  disease  or  generalized 
miliary  tuberculosis  is  characterized  by  gradual,  progressive 
weakness,  loss  of  appetite,  dry  clean  tongue,  constipation, 
flushed  cheeks,  irregular  fever,  the  temperature  seldom  going 
above  103°  or  104°  F.,  rapid,  feeble  pulse,  and  mild  delirium. 
The  respirations  are  increased  and  in  the  early  stage  cough  and 
expectoration  are  slight.  Frequently,  symptoms  of  a  diffused 
bronchial  catarrh  of  the  smaller  tubes  are  present.     Excessive 


ACUTE    MILIARY    TUBERCULOSIS.  I43 

sweating  is  common.  As  the  disease  progresses,  the  prostration 
becomes  more  profound,  cyanosis  develops,  and  delirium, 
stupor,   coma,   and  finally   death   supervene. 

Being  a  general  infection  of  asthenic  type,  it  is  liable  to  be 
mistaken  for  typhoid  fever.  The  chief  points  of  diflference 
are  the  absence  of  the  typical  typhoid  or  step-like  fever  record, 
roseolar  eruption,  diarrhea,  Widal  reaction,  and  diazo  reaction 
in  miliary  tuberculosis.  The  presence  of  tubercle  bacilli  and 
tubercles  in  the  retina  and  choroid  are  conclusive  evidences 
of  general  tuberculosis.  The  possibility  of  malaria  should  be 
eliminated  in  all  cases  by  examination  of  the  blood  for  the 
Plasmodium. 

Acute  general  tuberculosis  always  progresses  toward  a  fatal 
termination.  The  affection  seldom  lasts  more  than  six  or  eight 
weeks,  but  may  be  prolonged  for  a  greater  period.  The  treat- 
ment is,  therefore,  necessarily  unsatisfactory,  and  must  aim 
merely  at  relieving  distressing  symptoms.  Liquid  or  semisolid 
food,  such  as  milk,  eggs,  broths,  etc.,  and  stimulants  should 
be"  freely  administered.  Hydrotherapy  should  be  used  to 
control  the  fever  and  anodynes  should  be  employed  to  lessen 
the  cough  and  restlessness. 

The  puhnonary  variety  is  characterized  by  sudden  onset, 
with  chill  or  chilliness,  followed  by  fever,  102°  to  104°  F., 
rapid  dicrotic  pulse,  120  to  140  per  minute,  cough,  with  scanty, 
glairy  expectoration,  increased  respiration,  30  to  60  per  minute, 
pain  in  the  chest,  hot  skin,  dry  tongue,  and  deranged  digestion. 
Prostration  is  profound.  As  the  affection  advances,  the 
symptoms  increase  in  "severity;  cyanosis  soon  becomes  manifest; 
the  sputum  becomes  more  abundant  and  often  rusty  in  color; 
hemoptysis  may  occur;  emaciation  and  anemia  are  marked, 
and  later  there  supervene  headache,  vertigo,  sleeplessness, 
delirium,  coma,  and  death.  Tubercle  bacilli  and  elastic  fibers 
may  be  found  in  the  sputum,  and  an  examination  of  the  blood 
reveals  an  increase  in  the  number  of  white  cells  (leukocytosis). 
When  the  tubercles  are  formed  in  the  meninges  or  in  the 
intestinal  wall,  symptomis  referable  to  these  structures  are 
superadded, 


144  .  PNEUMONIC   PHTHISIS. 

The  physical  signs  are  not  constant.  The  percussion  reso- 
nance is  normal  until  the  deposits  become  considerable,  when 
it  is  either  slightly  impaired  or  at  times  even  tympanitic. 
With  the  development  of  cavities,  the  amphoric  percussion- 
note  may  be  obtained.  On  auscultation  often  very  little 
change  may  be  detected  in  the  vesicular  murmur,  but  diffused 
rales  of  bronchial  catarrh  may  be  heard.  In  some  cases, 
vesiculo-bronchial  breathing,  associated  with  large  and  small, 
moist  or  bubbling  rales  may  be  present,  soon  followed  by 
bronchial  and  bronchocavernous  breathing,  with  large  and  small 
circumscribed  moist  and  bubbling  rales. 

This  variety  terminates  in  death  in  from  four  to  twelve  weeks. 
In  rare  instances,  it  may  be  of  several  months'  duration.  It 
may  be  mistaken  for  typhoid  fever  with  marked  pulmonary 
complications,  but  a  careful  history  and  examination  of  the 
blood,  sputum,  and  urine  will  serve  to  make  the  proper  diagnosis. 

Treatment  is  of  no  avail  in  bringing  about  a  cure.  According 
to  Loomis,  morphin,  gr.  1/20  (0.003  S''^-)  hypodermically  every 
six  or  eight  hours,  is  of  great  benefit  in  staying  the  progress  of 
the  disease,  prolonging  life,  and  keeping  the  patient  comfortable. 
McCall  Anderson  states  that  subcutaneous  injections  of  atropin 
sulphate  check  the  exhausting  sweats,  and  that  quinin  sulphate, 
digitalis,  and  opium  reduce  the  fever.  As  an  alternative  to 
the  latter  procedures,  he  advises  ice-cloths  to  the  abdomen. 
Hydrotherapy  is  always  of  value  in  this  connection.  Free 
stimulation  is  always  necessary  and  the  various  symptoms 
should  be  combated  as  they  arise. 

For  the  cerebral  variety  see  Tubercular  Meningitis  (page  585), 

PNEUMONIC  PHTHISIS. 

Synonyms. — Chronic  catarrhal  pneumonia;  catarrhal  phthi- 
sis;   caseous    pneumonia;    caseous    phthisis;    phthisis   fiorida. 

Definition. — A  form  of  pulmonary  consumption  characterized 
by  the  destruction  of  the  pulmonary  tissue  resulting  from 
the  action  of  the  bacillus  tuberculosis,  causing  the  caseation 
or  cheesy  degeneration  of  inflammatory  products  in  the  lungs, 


PNEUMONIC    PHTHISIS.  1 45 

and  the  subsequent  softening  and  destruction  of  the  caseous 
matter ;  characterized  by  hectic  fever,  cough,  shortness  of  breath, 
purulent  expectoration,  and  more  or  less  rapid  prostration. 

Causes. — In  this  as  in  other  forms  of  tuberculosis,  the  tubercle 
bacillus  is  the  primary  cause.  A  condition  of  impaired  health, 
such  as  results  from  unhygienic  surroundings,  exposure,  or 
overwork,  or  such  as  accompanies  the  strumous  diathesis  or 
constitutional  diseases  is  an  important  contributory  cause. 
A  catarrhal  pneumonia  in  any  portion  of  the  lung,  but  especially 
at  the  apex,  inflammation  occurring  around  a  blood  clot,  and 
the  constant  inhalation  of  irritant  particles  are  also  factors 
of  great  etiologic  importance.  In  many  instances  the  disease 
follows  one  of  the  infectious  fevers. 

Pathologic  Anatomy. — The  tuberculous  infiltration  is  at 
first  peripheral  and  rapidly  leads  to  active  inflammation,  which  is 
manifested  as  a  bronchopneumonia,  the  bronchioles  and  air- 
vesicles  being  blocked  with  cheesy  material.  As  a  result, 
opaque  white  foci,  5  to  12  mm.  in  diameter,  are  disseminated 
throughout  the  lung,  between  which  are  congested  but  crepitat- 
ing areas.  The  diseased  foci  tend  to  soften,  rapidly  resulting 
in  small  abscess  cavities.  The  tuberculous  areas  may  be 
widely  separated,  or  may  be  limited  to  certain  regions,  especially 
the  apices.  The  process,  in  rare  instances,  may  be  grafted 
upon  a  lobar  pneumonia  in  which  resolution  has  failed  to 
occur.  It  may  be  distinguished  from  lobar  pneumonia 
by  the  greater  disintegration  of  tissue.  When  a  pneumonia 
terminates  in  resolution,  the  inflammatory  products  are 
absorbed  by  first  undergoing  a  fatty  metamorphosis.  If  the 
fatty  metamorphosis  be  incomplete,  the  cells  are  atrophied  and 
undergo  the  caseous  degeneration,  which  consists  in  the  ab- 
sorption of  the  watery  parts,  the  fatty  degeneration  of  the 
cellular  elements,  and  the  granular  disintegration  of  the  fibrin- 
ous material,  so  that  ultimately  a  soft,  solid  mass  is  produced, 
yellowish  in  color,  having  a  cheesy  appearance. 

The  situation  of  the  pneumonia  resulting  in  the  above 
changes  is  usually  at  the  apex  or  under  the  lower  inner  scapular 
region,  but  it  may  occur  at  any  portion  of  the  lungs,  or  a  whole 
10 


146  PNEUMONIC   PHTHISIS. 

lung  becomes  infiltrated  and  undergoes  the  cheesy  degenera- 
tion {phthisis  florida).  As  in  lobar  pneumonia  and  other  pneu- 
monic conditions,  there  is  a  great  tendency  toward  involvement 
of  the  pleura. 

Symptoms. — Pneumonic  phthisis  occurs  in  three  clinical 
forms — acute,  subacute,  and  chronic. 

The  acute  variety,  or  phthisis  florida,  so-called,  runs  a  very 
rapid  course,  beginning  either  as  a  croupous  or  catarrhal  pneu- 
monia involving  an  entire  lung  or  portions  of  both  lungs,  and 
is  accompanied  by  high,  but  variable,  temperature,  103°  to 
105°  F.,  remittent  in  type,  profuse  night-sweats,  shortness  of 
breath,  severe  cough,  profuse,  purulent,  and  blood-streaked 
expectoration  containing  tubercle  bacilli,  anorexia,  and  feeble, 
digestion.  There  is  rapid  loss  of  flesh  and  strength;  the  patient 
succumbing  in  a  few  weeks  or  months  from  exhaustion.  A 
decided  remission  in  the  local  and  general  symptoms  in  this 
form  may  take  place,  the  disease  afterward  pursuing  a  more 
chronic  course. 

In  the  subacute  variety  there  is  usually  a  history  of  an  acute 
attack  of  pneumonia  of  one  or  two  weeks'  duration,  which  is 
followed  by  decided  improvement,  but  not  by  complete  recovery. 
After  a  lapse  of  some  weeks  or  months  pulmonary  softening 
begins,  destroying  the  lung  structure  and  ultimately  leading 
to  cavity  formation.  These  changes  are  accompanied  by  chills, 
fever,  night-sweats,  emaciation,  cough,  and  muco-purulent  and 
blood-streaked  expectoration  containing  tubercle  bacilli.  The 
affection  terminates  fatally  within  a  year. 

In  the  chronic  form  the  origin  is  rather  insidious,  the  patient 
having  been  susceptible  to  "  colds"  or  "  catarrhs"  on  the  slight- 
est exposure  for  an  indefinite  period.  Cough  appears,  which 
gradually  becomes  persistent,  with  muco-purulent  expectoration. 
Each  severe  cold  is  accompanied  by  chill,  fever,  pain  in  the 
chest,  and  either  slight  hemorrhages  or  blood-streaked  ex- 
pectoration. Finally  the  catarrhal  symptoms  become  persistent 
and  attended  by  morning  chills,  evening  fever,  profuse  night- 
sweats,  distressing  cough,  and  profuse  muco-purulent  expectora- 
tion containing  tubercle  bacilli.      Loss  of  appetite  and  feeble 


\      -PNEUMONIC    PHTHISIS.  1 47 

digestion  are  present,  and  weakness  and  exhaustion  are  pro- 
found. The  symptoms  continue  to  grow  progressively  worse, 
death  occurring  from  exhaustion  in  from  one  to  two  years. 

Physical  Signs. — Inspection. shows  deficient  respiratory  move- 
ment over  diseased  portions  of  the  lungs.  The  respiratory 
rate  is  increased. 

Palpation  over  consolidated  areas  and  cavities  detects  in- 
creased vocal  fremitus. 

Percussion  reveals  definite  changes  in  lungs.  The  note  at 
the  apex  varies  from  slight  impairment  of  the  normal  note  to 
dullness,  and  when  cavities  are  formed  there  will  be  associated 
scattered  areas  over  which  the  tympanic  or  hollow  note  may 
be  obtained.  If  the  cavities  communicate  with  a  bronchial 
tube,  the  cracked-pot  or  cracked-metal  sound  is  elicited. 
When  the  cavities  are  filled  with  exudation  the  percussion  note 
will  be  dull,  but  after  expulsion  of  the  exudate,  the  tympanitic 
or  cracked-pot  sound  may  be  again  obtained. 
•  Aus dilation  detects  no  impairment  of  the  vesicular  murmur 
in  those  portions  of  the  lung  free  from  disease;  it  is  feeble  or 
indistinct  if  many  bronchioles  are  obstructed,  and  is  harsh  or 
blowing  if  the  bronchioles  are  narrowed.  After  the  lung  has 
lost  its  elasticity,  the  inspiratory  sound  will  be  jerking  and  the 
expiratory  sound  prolonged  and  blowing  in  character.  As- 
sociated with  the  impaired  vesicular  murmur  is  a  fine,  dry,  crack- 
ling sound  (crepitation),  appearing  at  the  end  of  inspiration. 
If  bronchitis  be  associated,  large  and  small  moist  or  bubbling 
rales  are  also  heard  during  respiration.  When  cavities  form, 
either  bronchial  or  bronchocavernous  respiration  is  heard, 
associated  with  more  or  less  distinct  gurgling  rales.  If  the 
cavity  be  free  from  pus  and  have  rather  firm  walls,  the  breath- 
ing is  more  amphoric  in  character. 

Diagnosis. — Catarrhal  bronchitis  has  many  points  of  resem- 
blance to  pneumonic  phthisis.  The  subsequent  course  of  the 
latter,  with  the  high  temperature,  prostration,  emaciation, 
sputum  containing  bacilli,  and  physicial  signs  will  prevent 
error. 

Acute  fibrinous  and  catarrhal  pneumonia,  often  after  a  course 


148  TUBERCULAR  I'HrKISIS. 

of  two  or  three  weeks,  show  the  bacilli  and  yet  are  not  recog- 
nized as  tuberculosis.  It  is  a  safe  rule  in  practice  to  suspect 
tuberculosis  and  examine  daily  for  the  bacilli  in  all  cases  of 
pneumonia  that  show  the  least  tendency  to  linger,  and  partic- 
ularly where  there  are  chills  and  a  remittent  temperature 
record. 

Prognosis. — Acute  phthisis  seldom  lasts  more  than  a  few 
months,  the  subacute  and  chronic  varieties  may  be  prolonged 
for  a  year  or  two  under  good  care  and  stimulating  treatment. 

TUBERCULAR  PHTHISIS. 

Synonyms. — Tuberculosis;  consumption;  incipient  phthisis; 
chronic  phthisis;  chronic  ulcerative  phthisis. 

Definition. — A  chronic  pulmonary  disease  caused  by  the 
bacillus  tuberculosis,  resulting  in  the  deposition  of  tubercle  in 
the  lung  structure,  which  in  turn  undergoes  ulceration  and 
softening,  inducing  septic  infection,  characterized  by  progress- 
ive failure  of  health,  fever,  cough,  dyspnea,  emaciation,  and 
exhaustion. 

Causes. — The  direct  cause  is  the  tubercle  bacillus.  A  sus- 
ceptibility to  its  influence  may  be  acquired  by  heredity,  syph- 
ilis, alcoholism,  chronic  nephritis,  occupations  necessitating 
cramped  postures,  inhalation  of  foul  air  and  irritating  particles, 
etc.,  residence  in  dark,  overcrowded,  and  damp  apartments, 
catarrhal  inflammation  of  the  respiratory  tracts,  and  the  in- 
fectious fevers.  Debility  from  any  cause,  and  early  adult 
life  are  important  predisposing  factors.  The  infection  usually 
takes  place  through  the  respiratory  tract. 

Pathologic  Anatomy. — Careful  examination  of  a  lung  affected 
with  this  form  of  tuberculosis  will  reveal  a  great  variety  of 
lesions.  Among  these  may  be  mentioned  nodular  tubercles, 
diffuse  infiltration,  caseated  masses,  pneumonic  areas,  and  cav- 
ities. Various  changes  may  also  be  noted  in  the  pleura,  bronchi, 
and  bronchial  glands.  The  primary  lesion  is  to  be  found  usually 
from  an  inch  to  an  inch  and  a  half  below  the  summit  of  the 
lung  and  near  to  the  posterior  and  external  borders  (Fowler). 
From  this  region,  the  extension  is  downward.     "  A  less  common 


TUBERCULAR    PHTHISIS.  1 49 

site  corresponds  on  the  chest  wall  with  the  first  and  second 
interspaces  below  the  outer  third  of  the  clavicle."  The  right 
apex  is  involved  first  in  the  majority  of  cases.  Basic  lesions 
are  seldom  primary. 

The  anatomical  lesion,  the  tubercle,  is  of  the  same  structure 
here  as  in  other  forms  of  tuberculosis.  It  first  appears  as  a 
grayish-white,  translucent,  semisolid  granulation,  about  the 
size  of  a  millet-seed ,  usually  deposited  in  the  walls  of  the 
bronchioles  or  around  the  small  blood-vessels.  From  its 
presence  in  these  situations  it  induces  a  low  form  of  inflam- 
mation which  ultimately  results  in  its  destruction.  The 
tubercles  then  undergo  softening  or  cheesy  necrosis  with  the 
formation  of  cavities  and  consequent  destruction  of  lung- 
tissue.  The  small  tubercles  may  coalesce,  forming  larger 
nodules,  or  diffuse  tubercular  infiltration. 

The  first  effect  of  the  tubercle  bacillus  is  the  formation  of 
oval  cells  having  a  vesicular  nucleus,  due  to  proliferation  of 
the  fixed  connective  tissue,  endothelium,  and  epithelium 
{epithelioid  cells).  These  constitute  one  of  the  characteristic 
features  of  the  tubercle.  In  the  center  of  this  accumulation 
may  be  found  at  a  later  period  a  larger  multinuclear  mass 
{the  giant  cell).  Round  or  lymphoid  cells  are  also  present  in 
abundance  and  may  obscure  the  other  cellular  elements.  New 
blood-vessels  are  never  present  in  the  tubercle,  but  the  process 
may  attack  vessel  walls  leading  to  their  subsequent  rupture 
and  hemorrhage.  The  bacilli  are  to  be  found  in  the  giant  cells, 
between  and  in  the  epithelioid  cells,  and  at  a  late  period  in  the 
round  cells.  The  cells  soon  become  arranged  concentrically, 
necrosis  beginning  in  the  center.  The  nodule  may  terminate 
in  calcification,  but  more  commonly  the  necrosis  and  liquefac- 
tion is  unchecked  and  cavity  formation  is  the  result. 

The  method  by  which  the  tubercle  bacillus  may  be  detected 
is  described  in  the  introduction  to  the  section  on  respiratory 
diseases,  (see  page  504). 

Symptoms. — The  onset  of  the  disease  is  very  insidious  and 
is  attended  by  anorexia,  dyspepsia,  epigastric  distress  after 
meals,  pallor,  anemia,  and  weakness,  all  of  which  may  serve 


150  TUBERCULAR    PHTHISIS. 

to  mislead  the  patient  and  physician.  Later  there  develops 
a  slight,  dry,  hacking  cough,  referred  to  the  throat  or  stomach 
and  occurring  usually  in  the  morning,  with  scanty,  glairy 
expectoration.  As  the  deposition  of  the  tuberculous  disease 
progresses  there  occur  irritable  heart,  gradual  loss  of  weight, 
with  impaired  strength,  more  or  less  copious  hemoptysis,  and 
sharp  pain,  most  marked  below  the  clavicles.  Slight  "colds" 
serve  to  aggravate  all  of  these  manifestations. 

The  beginning  of  softening  of  the  diseased  area  is  marked  by 
increased  cough,  with  free  expectoration  containing  tubercle 
bacilli  and  elastic  tissue  fibers,  dyspnea  increased  on  exertion, 
morning  chills,  evening  fever,  and  night-sweats  (hectic  fever), 
and  diarrhea.  The  emaciation  and  weakness  become  profound, 
but  the  patient  continues  to  be  very  hopeful. 

With  the  formation  of  cavities,  the  cough  becomes  more  ag- 
gravated. Expectoration  is  profuse  and  purulent;  it  may  be 
greenish  in  color  and  made  up  of  heavy  coin-shaped  plugs, 
which  sink  when  placed  in  water  (nummular  sputum).  Tuber- 
cle bacilli  and  yellow  strise  are  present.  The  pulse  is  rapid  and 
weak.  Hectic  fever  becomes  more  pronounced;  the  face  is 
flushed ;  the  eyes  are  bright ;  a  sensation  of  burning  of  the  soles 
and  palms  is  present;  and  there  are  more  copious  night-sweats. 
Hemoptysis  may  occur  at  any  time  during  the  disease,  but  it 
is  only  during  the  latter  part  of  this  period  that  the  profuse 
hemorrhages  are  encountered.  The  blood  in  such  cases  is 
bright  red,  alkaline  in  reaction,  and  mixed  with  mucus.  The 
emaciation,  pallor,  and  weakness  become  extreme.  Edema  of 
the  ankles  occurs  toward  the  end  of  the  disease,  indicating 
failure  of  the  circulation.  The  mind  remains  clear  and  hopeful 
to  the  last. 

Physical  Signs. — Inspection  during  the  early  stage  shows 
slight  depressions  in  the  supraclavicular,  and  at  times  in  the 
infraclavicular,  regions.  While  the  configuration  of  the  chest 
may  be  unchanged,  it  is  more  common  to  encounter  the  long, 
flat  chest,  with  oblique  ribs,  prominent  scapulae,  and  deep  de- 
pressions above  and  below  the  clavicles  on  either  side  (phthi- 
sical  chest).     As   the   disease   advances,    the   emaciation,  uni- 


TUBERCULAR   PHTHISIS.  151 

lateral   expansion,   and   localized  retraction  may  be  observed. 

Palpation  serves  to  detect  increased  vocal  fremitus  over 
either  or  both  apices,  and  imperfect  expansion. 

Percitssion  yields  a  slightly  impaired  note  in  the  early  stage 
at  either  or  both  apices.  When  the  manifestations  of  the 
disease  are  prominent,  dullness  may  be  obtained  over  the  con- 
solidated areas.  The  regions  in  which  it  is  most  readily  elic- 
ited are  above  and  below  the  clavicles,  in  the  supraspinous 
fossae,  and  between  the  scapulae.  In  the  period  of  cavity- 
formation  dullness  may  be  detected  with  circumscribed  areas 
of  the  amphoric,  tympanitic,  or  cracked-pot  sound.  In  order 
to  obtain  the  cracked-pot  sound  over  cavities,  the  patient 
should  hold  the  mouth  open  and  the  chest  should  be  struck 
quickly  and  lightly. 

Ausculation  reveals,  in  the  early  stage,  jerky  inspiration  with 
crackling  rales  at  the  apex,  and  prolonged,  high  pitched  expira- 
tion. Later  the  breathing  becomes  distinctly  harsh  and  is  asso- 
ciated with  subcrepitant,  and  large,  moist,  or  bubbling  rales. 
There  is  increased  vocal  resonance.  Coughing  will  always 
serve  to  render  the  rales  audible.  In  the  stage  of  cavity- 
formation  bronchial,  bronchovesicular,  and  cavernous  or 
amphoric  breathing  are  obtained,  and  variously  sized  bubbling 
or  gurgling  rales  are  heard.  Bronchophony,  and  pectoriloqu}^ 
may  be  elicited. 

Complications. — The  tuberculous  process  may  simultaneously 
affect  the  brain  and  its  membranes,  nerves  of  special  sense, 
larynx,  pleura,  intestines,  peritoneum,  ischiorectal  cellular 
tissue,  endocardium,  or  pericardium,  the  symptoms  of  which 
are  then  superadded  to  those  referable  to  the  pulmonary  condi- 
tion. Amyloid  degeneration  of  the  viscera  is  a  common 
complication. 

Diagnosis. — The  early  diagnosis  of  phthisis  rests  largely  on 
the  history,  the  symptoms,  especially  the  gastric  disturbances, 
evening  fever,  and  accelerated  pulse,  and  the  physical  signs. 
The  presence  of  the  tubercle  bacillus  in  the  sputum  is  conclusive 
evidence  of  the  disease.  In  all  suspected  cases,  the  chest  and 
the  expectoration  should  be  carefully  examined. 


152  FIBROID    PHTHISIS. 

Other  recent  diagnostic  tests  consist  in  the  administration 
of  tuberculin,  the  Calmette  ophthalmo-reaction,  and  the  ag- 
glutination and  serum  tests.  In  the  tuberculin  test,  i  mgm. 
is  injected  subcutaneously,  and  if  no  reaction  occurs  a  larger 
dose  of  2  or  3  mgm.  is  administered  after  two  or  three  days. 
Within  ten  to  twelve  hours  the  reaction  occurs  with  a  rise  of 
temperature  to  102°  or  104°  F.  In  Calmette's  reaction,  a  drop 
of  a  1/2  to  I  per  cent,  solution  of  tuberculin  is  put  on  the  con- 
junctiva; in  infected  individuals  the  conjunctiva  becomes 
hyperemic. 

Prognosis. — Generally  speaking,  the  outlook  is  very  unfavor- 
able. The  duration  is  usually  about  two  years,  death  occur- 
ring from  exhaustion.  Many  cases  under  the  influence  of  good 
hygiene,  sunshine,  stimulating  food,  dry  rarefied  atmosphere, 
and  appropriate  treatment  of  every  symptom,  are  prolonged  a 
more  or  less  indefinite  period.  Arrest  of  the  disease,  when  it 
occurs,  is  due  to  calcification  of  the  tubercles.  The  unfavor- 
able symptoms  are  rapid  pulse,  high  temperature,  marked 
gastric  disturbances,  and  manifestations  due  to  tuberculosis 
elsewhere  in  the  body. 

FIBROID   PHTHISIS. 

Synonyms. — Chronic  interstitial  pneumonia;  cirrhosis  of 
the  lungs ;  Corrigan's  disease. 

Definition. — A  hyperplasia  (thickening)  of  the  pulmonary 
connective  tissue,  resulting  in  atrophy  and  degeneration  of 
the  vesicular  structure,  associated  with  bronchial  inflammation; 
characterized  by  cough,  profuse  expectoration  containing  the 
bacillus  tuberculosis,  fever,  emaciation,  and  ultimately  death 
by  asthenia. 

Causes. — The  exciting  cause  is  the  tubercle  bacillus,  but  hered- 
ity, inhalation  of  irritants,  such  as  occurs  in  the  pursuit  of 
occupations,  such  as  stone-cutting,  grinding,  mining,  etc.,  lobar 
pneumonia,  chronic  bronchitis,  alcoholism,  syphilis,  and 
chronic  nephritis  should  be  remembered  as  important  etiologic 
factors. 

Pathologic  Anatomy. — The  characteristic  anatomical  feature 


TREATMENT   OF   PULMONARY   TUBERCULOSIS.  1 53 

of  this  disease  is  the  marked  development  of  fibrous  tissue  in 
addition  to  the  tubercular  process  in  the  lung.  Contraction 
of  the  fibrous  tissue  and  shrinking  of  the  affected  lung  result. 

Symptoms. — The  affection  is  extremely  chronic,  beginning 
as  a  bronchial  catarrh,  which  is  worse  in  winter  and  better 
in  summer,  extending  over  a  long  period.  In  the  more  ad- 
vanced stages  of  this  disease,  the  cough  is  more  persistent  and 
expectoration  is  more  copious,  being  made  up  of  a  muco- 
purulent material  containing  tubercle  bacilli.  Later  hectic 
fever,  with  night-sweats,  develops,  and  dyspnea  and  rapid 
emaciation  become  manifest.  Edema  of  the  ankles  is  a  late 
sign  and  depends  on  failure  of  the  circulation.  The  termination 
is  eventually  in  death. 

Physical  Signs. — Inspection  reveals  marked  retraction  of 
the  affected  side,  due  to  shrinking  of  the  diseased  lung. 

Percussion  yields  a  dull  note  or  impaired  resonance,  with 
scattered  areas,  over  which  hyper-resonance  or  tympany  may 
be  obtained. 

Auscultation  in  the  early  stage  serves  to  elicit  vesiculo- 
bronchial or  harsh  respiration,  associated  with  large  and  small 
moist  or  bubbling  rales,  but  at  a  later  period  bronchial,  broncho- 
cavernous,  and  cavernous  breathing,  with  circumscribed  gurg- 
ling rales,  may  be  heard. 

Diagnosis. — The  distinctive  features  are  the  prolonged  course, 
the  bronchial  catarrh  worse  during  the  winter,  retraction  of  the 
lung,  and  the  presence  of  the  'tubercle  bacillus  in  the  sputum. 

Prognosis. — Death  is  the  inevitable  termination  of  this 
disease,  but  the  course  of  the  affection  extends  over  a  period 
from  six  to  twelve  years.  Da  Costa,  in  a  study  of  one  hundred 
cases  of  "grinder's  consumption,"  found  the  average  duration 
to  be  about  twelve  years  from  the  development  of  the  first 
symptoms. 

TREATMENT  OF  PULMONARY  TUBERCULOSIS. 

Prophylatic  Treatment. — The  presence  of  the  tubercle  bacil- 
lus in  the  sputum  renders  that  substance  a  source  of  great 
danger    since,    after   being    dried,    it    is    rapidly    disseminated 


154  TREATMENT    OF    PULMONARY    TUBERCULOSIS. 

throughout  the  atmosphere.  The  sputum  of  all  tuberculous 
patients  should  therefore  be  thoroughly  disinfected  by  means 
of  milk  of  lime,  carbolic  acid  solution  (i  to  30),  or  caustic 
alkalies.  Receptacles  in  which  the  sputum  is  collected  should 
contain  a  small  quantity  of  water  to  prevent  evaporation, 
and  should  be  scalded  in  cleaning.  Paper  napkins,  paste- 
board spit-cups,  rags,  and  similar  inexpensive  materials  may 
be  used  to  receive  the  expectoration  and  possess  the  great 
advantage  that  they  may  be  destroyed  completely  by  heat. 
Spitting  upon  the  floor  or  in  places  other  than  the  especially 
provided  receptacles  should  be  prohibited.  Excessive  drapery 
and  superfluous  upholstery  that  do  not  permit  of  being  easily 
cleaned,  should  be  removed  from  the  apartments  of  the  tuber- 
culous patient.  The  possibility  of  infection  by  means  of  milk 
and  meat  should  always  be  considered.  Infected  meat  and 
milk  should  be  rejected  as  food,  but  an  additional  safeguard 
will  be  to  thoroughly  cook  all  meat  and  boil  all  suspected 
milk.  Residence  in  low,  damp,  shaded  localities  should  be 
avoided  by  those  individuals  predisposed  to  the  disease — fresh 
air,  sunshine,  and  out-door  exercise  should  be  advised.  A  high 
altitude  where  the  air  is  dry  and  rare,  and  the  climate  equable, 
is  of  great  advantage  to  such  persons.  Bathing  and  cold 
sponging,  wholesome  diet,  and  moderation  in  eating  and  drink- 
ing, should  be  prescribed.  Localized  foci  of  the  disease  should 
receive  prompt  attention. 

Climatic  Treatment. — Circumstances  permitting,  all  patients 
in  whom  tuberculosis  is  detected,  should  be  sent  to  a  suitable 
climate.  Those  of  a  robust  type  are  benefited  by  high  altitude 
and  cold,  and  a  certain  degree  of  hardship  or  "roughing  it." 
The  change  should  be  gradual.  Disturbance  of  the  circulatory 
system,  cardiac  weakness,  small  size  of  the  heart,  neurotic 
temperament,  and  persistent,  high  temperature  contraindicate 
such  a  change  in  climate.  Those  who  require  protection  should 
seek  a  residence  in  warm  or  equable  and  comparatively  dry 
places  at  the  sea-level,  or  but  slightly  elevated.  In  early  cases, 
attended  by  persistent,  high  temperature,  a  sea  voyage  may  be 
of  great  benefit.     Colorado  and  New  Mexico  represent  the  high 


TREATMENT    OF    PULMONARY   TUBERCULOSIS.  1 55 

and  dry  climates,  while  Southern  California  may  be  taken  avS 
the  type  of  warm  and  dry  climates;  warm  and  moist  climates 
are  encountered  on  the  coast  of  Southern  California  and  in 
Florida.  When  for  any  reason  it  is  impossible  to  move  the 
patient  any  distance,  much  can  be  done  by  placing  the  in- 
dividual in  some  nearby  country  place,  preferably  among  the 
hills  and  away  from  damp  regions.  Plenty  of  fresh  air  and 
sunshine  may  then  be  obtained.  The  city  is  no  place  for 
the  consumptive,  but  the  possibility  of  nostalgia  and  its 
deleterious  effects  should  always  be  considered  when  ordering  a 
change. 

Hygienic  Treatment.— The  apartment  in  which  the  patient 
spends  the  greater  portion  of  the  day  should  be  free  from  damp- 
ness and  so  situated  as  to  be  accessible  to  sunlight  for  as- many 
hours  as  possible.  The  atmosphere  should  not  be  too  dry,  as 
cough  and  subsequent  hemorrhage  may  be  induced  thereby. 
The  temperature  should  average  65°  F.  It  is  desirable  that 
the  bedroom  be  occupied  only  at  night,  and  be  w^ell  ventilated 
during  the  day.  The  clothing  should  be  warm  and  loose,  being 
changed  with  the  seasons.  Woolen  or  silk  underwear  should 
be  worn  throughout  the  year.  Heavy,  oppressive  clothing  should 
be  avoided.  Frequent  changes  are  necessary  for  obvious 
reasons.  Daily  bathing,  followed  by  friction,  is  recommended. 
Cold  sea-bathing  is  harmful.  Rest  and  exercise  in  varying 
degrees  in  combination  are  beneficial.  Exhaustion  should 
alv/ays  be  avoided.  Robust  individuals  may  partake  of  out- 
door exercise  with  benefit,  while  weak  and  anemic  patients 
require  rest  and  passive  movements.  The  presence  of  high 
fever  is  always  an  indication  for  rest.  Exposure  to  sunlight 
is  very  beneficial.  Sedentary  occupations  should  be  avoided. 
The  patient  should  be  constantly  amused.  Nutritious  food, 
such  as  meats,  poultry,  game,  oysters,  fish,  animal  broths, 
milk,  eggs,  etc.,  is  always  indicated.  The  quantity  should  be 
liberal.  Nothing,  however,  should  be  fried.  Among  the  arti- 
cles to  be  avoided  may  be  mentioned  pork,  veal,  hot  bread, 
cakes,  pies,  pastry,  sweetmeats,  rich  gravies,  crabs,  lobsters, 
etc.      Water  should  be  taken  freely.      Whiskey,  cod-liver  oil,  and 


156  TREATMENT   OE   PULMONARY   TUBERCULOSIS. 

stomachics  aid  the  building  up  of  the  system  and  should  be 
given  with  the  food.  Great  care  should  be  exercised  not  to 
discomfort  the  patient  by  overfeeding. 

Medicinal  Treatment. — Medicines  should  be  administered 
for  their  general  constitutional  effect  and  also  to  relieve  dis- 
tressing symptoms.  Cure,  when  it  is  effected,  is  only  brought 
about  by  improving  the  general  health  and  restoring  the  tone 
and  resistance  of  the  body.  To  this  end,  cod-liver  oil,  hy- 
pophosphites,  alcohol,  arsenic,  and  strychnin  should  be  ad- 
ministered freely.  Plain  cod-liver  oil,  combined  with  the  hy- 
pophosphites  of  calcium,  sodium,  and  potassium  (U.  S.  P. )  is 
an  excellent  preparation,  and  when  given  with  whiskey  is  not 
distasteful.  A  tablespoonful  twice  daily  is  as  large  a  dose  as 
can  be  employed  without  disturbing  the  stomach.  Should 
this  occur,  or  as  is  usually  the  case,  if  there  is  indigestion  from 
other  causes,  nux  vomica,  gentian,  or  other  stomachics  should 
be  given.     The  following  is  very  beneficial  in  this  connection: 

I^.      Strychninae  sulphat gr.  iv  .26  gm. 

Aq.  chloroformi,  vel .... 

Ess.  pepsini 5ij  60.       c.c. 

M.  S. — Ten  minims  equal  gr.  1/24  of  strychnin  (0.0025  g^"^-)- 

Mode  of  administration:  Five  drops  three  times  daily  for 
one  week,  then  10  drops  three  times  daily  for  a  week,  then  15 
drops  three  times  daily  for  a  week,  then  20  drops,  three  times 
daily  for  a  week,  then  15  drops,  then  10  drops,  then  5  drops,  and 
so  on  week  after  week  for  months. 

Whiskey  and  brandy  should  be  given  in  cases  in  which  the 
asthenia  is  at  all  marked,  the  dose  being  guided  by  the  effect 
produced  and  the  exigencies  of  the  individual  case.  A  rise  of 
temperature  and  dyspepsia  indicate  withholding  the  alcohol. 
Arsenic  is  of  great  value  also  and  may  be  given  in  the  form  of 
Fowler's  solution  (not  exceeding  5  minim  doses),  or  combined 
with  digitalis. 

Strychnin  sulphate,  gr.  1/60  to  1/30  (0.00 1  to  0.002  gm,), 
after  meals  and  guaiacol,  Tr^iii  to  v  (0.2  to  0.3  c.c.)  for  adults, 


TREATMENT   OF    PULMONARY   TUBERCULOSIS.  1 57 

and  rtiii  to  iii  (0.12  to  0.2  c.c.)  for  children,  four  times  daily,  are 
of  value.  Creasote,  gr.  i  (0.6  gm.)  after  each  meal  gradually 
increasing  the  dose,  and  creasotol,  beginning  with  10  minims 
(0.66  c.c),  are  also  beneficial.  The  inhalation  of  modified  air 
(pneumotherapy)  and  atmospheres  saturated  with  the  vapors 
of  iodin,  creasote,  carbolic  acid,  etc.,  has  been  employed  with 
success.  Counterirritation  of  the  chest  with  blisters  may  be 
considered  in  obstinate  cases. 

Serum  treatment  may  be  accompanied  by  encouraging  results 
in  some  cases.  The  refined  tuberculin  of  Koch  should  be  used 
and  should  be  administered  in  doses  short  of  that  necessary  to 
produce  febrile  reaction.  The  first  dose  should  never  exceed  0.2 
mgm.,  and  should  be  given  hypodermically.  The  earlier  it  is 
employed,  the  more  localized  the  disease,  and  the  less  general 
the  infection,  the  greater  will  be  the  prospect  of  good  results 
from  its  use.  In  cases  in  which  fever  and  hemorrhage  are 
present,  it  is  contra-indicated.  The  presence  of  mixed  infection 
renders  it  useless.  The  results  from  its  use  in  the  wards  of  the 
Philadelphia  Hospital  were  uniformly  negative.  It  is  not 
devoid  of  danger,  and  is  of  most  value  as  a  diagnostic  agent. 

The  cough  of  pulmonary  tuberculosis  when  slight  may  be 
readily  relieved  by  the  application  of  a  mustard  plaster,  cap- 
sicum plaster,  iodin,  turpentine  stupe,  or  a  fly-blister  to  the 
chest  over  the  region  of  most  distress.  Internally,  cresote,  nii 
(0.06  c.c),  in  milk  or  whiskey,  three  times  daily,  gradually 
increasing  the  dose,  dilute  hydrocyanic  acid,  iTLii  to  iv  (0.12  to 
0.24  c.c),  terebene,  rtxiii  to  x  (0.18  to  0.62  c.c),  and  similar 
expectorants  should  be  administered.  The  various  prepara- 
tions of  opium,  especially  paregoric,  5i  (3.6  gm.),  morphin, 
gr.  1/24  to  1/4  (0.00275  "to  0.0165  gm.),  codein,  gr.  1/4  (0.0165 
gm.),  and  heroin,  gr.  1/20  (0.0033  gm.),  are  of  particular  value 
in  relieving  this  symptom. 

I^.      Codeinae  sulphat gr.  1/3  to  1/2  .022  to  032  gm. 

Acidi  hydrocyanici  dil. .  .     n\ij  .  12  c.c. 

Syr.  tolu O  j  4  .  c.c. 

M.  S. — One  dose,  to  be  given  every  three  hours. 


158  TREATMENT    OF    PULMONARY    TUBERCULOSIS. 

Or— 

I^.      Codeinae gr.  iv  .26  gm. 

Acid  hydrochlor.  dil  ....     oss  2 .       c.c. 

Spirit,  chloroformi oiss  6.        c.c. 

Syr.  limonis Bj  30.        cc- 

Aq.  lauro-cerasi  .q.  s.  ad    5iv  ad  120.        c.c. 
M.    S. — One   teaspoonful,   repeated    when   cough   is   trouble- 
some. 

Or— 

I^.      Morphin.  sulphat gr.  ss  to  ii       o  .  033  to  0.130  gm. 

Potass,  cyanid. gr.  iii  0.2  gm. 

Acid,  sulph.  aromat f  5i  to  ii  4  .  to  8  .  c.c. 

Syrup,  prun.  Virgin,  q.  s. 

ad  fSiii  90    c.c. 

M.    S. — Tablespoonful    as    often    as  necessary   to    quiet   the 
cough  (Tyson). 

When  coughing  is  harassing  or  expectoration  is  difficult,  as  it 
often  is  in  the  morning,  whiskey  or  a  milk  punch  should  be  given 
in  preference  to  any  sedative. 

In  the  pneumonic  variety,  the  attempt  should  always  be 
made  to  remove  the  caseous  matter  by  absorption  and  expec- 
toration. The  following  prescriptions  will  sometimes  prove 
successful : 

I^.      Ammonii  carb gr-v  .  3  gm. 

Ammonii  iodidi gr.v  .  3  gm. 

Aq.  chloroformi 5ij  8.      c.c. 

Syr.  prun.  virg '.     oij  8  .     c.c. 

M.  S. — Every  five  hours,  diluted. 

Alternating  with — 

I^.      Liq.  potassii  arsenitis.  .  .  rr^v  .3  c.c. 

Mass.  ferri  carb grv  .3  gm. 

Vini  xerici f  5  j  4  .     c.c. 

Aquag q.  s.  ad  f  5ss  15  .     c.c. 

Dyspeptic  symptoms  are  nearly  always  present,  but  may  be 
aggravated  by  internal  medication,  in  which  cases  the  offend- 


TREATMENT    OF    PULMONARY   TUBERCULOSIS.  1 59 

ing  drugs  should  be  lessened  in  dose  or  even  temporarily  sus- 
pended. These  manifestations  should  be  treated  on  general 
principles,  the  following  formulas  will  often  be  found  of  benefit: 

I^.      Pepsini  cryst gr  ij  .13  gm. 

Acidi  hydrochlorici  dil .  .     rqxv  i .        c.c. 

Glycerini ti^xx  i  .  3     c.c. 

Succi  limonis tt\xv  i  .       c.c. 

Aquas  aurantii  fior  .q.s.  ad  f  oij  ad  8  .        c.c. 

M.  S. — To  be  taken  with  meals,  diluted;  or: 

I^.      Liquor,  potassii  arsenitis     ttlxxx  2 .  c.c. 

Tincturse  nucis  vomicae .  .    f5j  4-  c.c. 

Aquae  chloroformi .  .  .  .  ad  f  §ij  ad  60.  c.c. 

M.  S. — Teaspoonful  before  meals,  diluted. 

Fever  may  be  materially  lessened  by  rest  alone,  but  in  the 
event  of  its  failing  to  do  so,  cool  sponging  or  the  use  of  phenace- 
tin  or  antipyrin  will  be  necessary. 

■The  following  is  effectual  (but  as  a  rule  quinin  should  be 
avoided) : 

I^.      Quininae  sulphat gr.  x  .6  gm. 

Quininse  hydrochlorid .  .  .    gr.  x  .6  gm. 

Pulv.  opii  et  ipecac gr.  iij  .  2  gm. 

M.     Ft.  capsul.  No.  ij. 

S. — One  capsule  five  hours  and  the  other  three  hours  before 
the  expected  rise  of  temperature. 

Night-sweats  are  especially  troublesome  and  may  be  relieved 
to  a  great  extent  by  the  administration,  at  bed-time,  of  atropin 
sulphate,  gr.  i/ioo  to  1/60  (0.00066  to  o.ooii  gm.),  agaric 
acid,  gr.  1/8  to  1/4  (0.0082  to  0.0165  g^-)>  camphoric  acid,  gr. 
XX  to  XXX  (1.32  to  2  gm.),  picrotoxin,  gr,  1/60  (o.ooii  gm.), 
or  aromatic  sulphuric  acid,  gtt.  x  to  xx  (0.6  to  1.3  c.c).  Spong- 
ing of  the  body  at  bed-time  with  astringent  solutions,  such  as 
the  solution  of  alum  and  solution  of  white  oak  bark,  or  with  alco- 
hol, is  beneficial.  Tyson  recommends  a  lotion  of  balsam  of 
Peru,  I  part;  formic  acid,  5  parts;  chloral  hydrate,  5  parts;  tri- 
chloracetic acid,  I  part;  absolute  alcohol,  100  parts. 


l6o  LEPROSY. 

Diarrhea  in  the  course  of  phthisis  is  greatly  benefited  by  the 
administration  of  bismuth  subnitrate,  gr.  xx  (1.3  gm.),  every 
three  or  four  hours,  with  rest  in  bed  and  mustard  to  the  abdo- 
men.    The  following  may  be  used : 

I^.     Cupri  sulphat gr.  iss  o.  i  gm. 

Ext.  nucis.  vomicae gr.  iii  0.2  gm. 

Pulv.  opii gr.  vi  0.4  gm. 

M.     Ft.  pil.  No.  xii. 

S. — One  every  four  hours. 

Or— 

I^.     Liq.  potass,  arsenit ttlxxx  2.     c.c. 

Tr.  opii  deodorat f  5iss  6.     c.c. 

Liq.  pepsini q.  s.  ad  f  5ii  60.0  c.c. 

M.  S. — Teaspoonful  at  each  meal. 

Hemoptysis  is  best  treated  by  absolute  rest,  with  the  applica- 
tion of  an  ice-bag  to  the  chest  and  the  administration  of  mor- 
phin,  gr.  1/4  (0.016  gm.)  hypodermically.  Of  almost  equal 
value  are  atropin  sulphate,  gr.  1/200  to  1/60  (0.00032  to  o.ooi 
gm.),  and  spirits  of  glonoin  (nitroglycerin),  nxi  (0.06  c.c). 
Gallic  acid,  salt,  ergot,  gelatin,  and  suprarenal  extract  are  also 
recommended.  If  the  hemorrhage  is  profuse  the  extremities 
should  be  circularly  constricted  by  ligatures.  The  various 
measures  usually  advised  for  internal  hemorrhage  under  other 
circumstances  are  applicable. 

Pains  in  the  chest  are  rather  common.  Strapping  of  the  chest, 
mild  counter-irritation,  or  morphin  hypodermically,  will  be 
required,  according  to  their  severity. 

LEPROSY. 

Synonym. — Elephantiasis  Graecorum. 
Definition. — A  chronic  infectious  disease,  due  to  the  bacillus 
leprae,  characterized  by  tubercular  nodules  in  the  skin  and 
mucous  membranes,  {tubercular  leprosy);  also  by  infiltration 
of  the  nerve  trunks  {anesthetic  lepron) ;  perversion  of  sensation 
and  progressive  mutilation  may  follow. 


LEPROSY.  l6l 

Etiology.- — The  specific  cause  is  the  bacillus  leprae,  which 
closely  resembles  the  tubercle  bacillus;  how  it  is  transmitted 
is  not  settled.  Contagion,  heredity,  inoculation,  diet,  the  air, 
and  intermediate  hosts  (mosquitoes,  fleas,  and  bed-bugs),  have 
all  been  considered  etiological  factors. 

The  following  are  the  conclusions  of  the  Indian  Leprosy 
Commission: 

1.  Leprosy  is  a  disease  sui  generis,  and  not  a  manifestation 
of  syphilis  or  tuberculosis. 

2.  It  is  not  hereditary. 

3.  It  must  be  regarded  as  contagious  and  inoculable. 

4.  It  is  not  originated  by  food,  climate,  or  insanitary  sur- 
roundings, but  these  causes  may  predispose  to  the  disease. 

5.  The  method  of  origination  is  unknown. 

Morbid  Anatomy. — The  typical  lesion  is  a  nodule  in  the  skin 
or  mucous  membrane.  This  is  of  variable  size,  consisting  of 
epithelioid,  lymphoid  and  giant  cells  in  a  connective  tissue 
stroma,  within  and  between  which  the  bacilli  may  be  found. 
The  nodule  is  vascular,  thus  differing  from  the  tubercle.  The 
bacilli  may  also  be  found  in  the  peripheral  nerve  fiber  in  the 
anesthetic  variety.  The  face,  hands  and  feet  may  be  terribly 
disfigured,  the  phalanges  may  drop  ofl,  and  the  internal  organs 
become  the  sites  of  nodular  formation;  the  lungs,  liver  and 
spleen  being  specially  involved.  The  nerves  most  frequently 
involved  are  the  facial,  median,  ulnar,  radial,  posterior  tibial 
and  peroneal. 

Diagnosis. — This  is  made  by  finding  the  specific  bacillus. 
The  diagnosis  of  typical  cases  presents  no  difficulty  to  those  who 
have  seen  lepers. 

Prognosis  and  Treatment. — The  disease  is  incurable,  but  the 
patient  may  live  a  very  long  time.  Segregation  should  be 
insisted  on.  The  most  useful  remedy  is  probably  Chaulmoogra 
oil;  this  is  given  by  inunction  over  the  affected  areas,  and  also 
internally.  It  should  be  rubbed  in  twice  a  day,  and  given  in 
capsules  by  the  mouth,  beginning  with  10  minims,  and  gradually 
increasing  till  the  digestion  is  disturbed,  when  the  dose  must 
be  reduced  for  a  time.  This  must  be  persisted  in  for  a  long  time. 
II 


I 62  GLANDULAR    FEVER. 

At  the  same  time  the  general  health  must  be  attended  to  and 
fresh  air,  exercise,  tonics  and  suitable  diet  must  be  insisted 
on.  Sodium  chlorid  in  the  food  is  said  to  be  injurious  to  the 
bacilli.  Other  remedies  that  have  been  used  are  gurjun  oil, 
potassium  iodid,  cresote,  and  salicylic  acid. 

GLANDULAR  FEVER. 

Definition. — An  acute  infectious  disease,  generally  occurring 
in  childhood,  and  characterized  by  sudden  onset,  moderate 
fever,  swelling  of  the  cervical  lymphatic  glands,  and  constipa- 
tion; but  there  is  no  rash.      It  is  probably  contagious. 

Etiology. — The  cause  is  unknown.  The  infectious  agent, 
whatever  it  may  be,  is  said  to  enter:  (i)  through  the  tonsils 
or  pharynx,  or  (2)  by  way  of  the  intestines.  Predisposing  causes 
are:  winter  months,  previous  illness,  powered  vitality,  and 
general  malnutrition. 

Symptoms. — The  incubation  period  is  about  five  to  eight 
or  ten  days,  and  is  without  symptoms.  The  acute  symptoms 
appear  suddenly;  there  are  pain  and  tenderness  in  the  neck, 
and  these  are  made  worse  by  movement  of  head  or  neck  and 
by  swallowing;  fever  occurs  early,  it  is  remittent,  and  not 
severe,  running  to  about  101°  or  103°  F.  The  face  may  be 
flushed,  but  there  is  no  rash.  There  may  be  nausea,  anorexia, 
vomiting,  and  abdominal  pain.  The  throat  and  pharynx 
show  inflammation,  and  there  is  some  dysphagia.  The  lym- 
phatic glands  are  enlarged,  and  some  of  them  can  be  palpated, 
particularly  those  in  the  cervical  and  carotid  regions,  just 
below  and  near  the  anterior  border  of  the  sterno-mastoid. 
The  posterior  cervical,  axillar}^  and  inguinal  glands  may  also 
be  affected ;  and  abdominal  tenderness  with  enlarged  liver  and 
spleen  will  then  be  noticed.  The  fever  abates  as  the  gland 
involvement  reaches  its  height,  and  the  latter  may  last  twelve 
or  fourteen  days,  while  the  fever  remains  only  three  or  four 
days. 

Complications. — The  most  serious  complication  is  nephritis; 
suppuration  of  the  glands  is  not  very  common;  otitis  media 


CHRONIC  ARTICULAR    RHEUMATISM.  1 63 

and  retropharyngeal  abscess  may  also  occur.  In  severe  cases 
the  beginning  of  convalescence  is  often  marked  by  the  passage 
of  thin  greenish  stools,  containing  mucus. 

Diagnosis. — This  is  to  be  made  from  the  symptoms,  particu- 
larly the  cervical  adenitis ;  the  diseases  to  be  excluded  are  pharyn- 
gitis, tonsillitis,  parotitis,  and  leukemia. 

Prognosis  is  favorable,  except  when  the  case  is  complicated 
by  nephritis. 

Treatment. — This  is  almost  entirely  symptomatic.  Isola- 
tion should  be  insisted  on  so  as  to  prevent  the  spread  of  the 
disease.  Rest  is  necessary;  the  pain  may  be  relieved  by  hot 
applications;  iron,  cod  liver  oil,  light  but  nutritious  food,  and 
general  hygienic  precaution  are  all  indicated.  Calomel  in 
small  doses  has  been  recommended,  and  also  condemned.  For 
the  adenitis,  applications  of  belladonna  should  be  made;  and 
when  the  fever  is  high  (in  the  early  stage  of  the  disease)  or  the 
pain  is  severe,  sodium  salicylate  may  be  given.  If  the  glands 
suppurate,  incision  and  drainage  will  be  in  order. 

CONSTITUTIONAL    DISEASES. 
CHRONIC    ARTICULAR    RHEUMATISM. 

Causes. — The  affection  may  follow  an  acute  or  subacute 
attack,  but  in  most  cases  it  is  chronic  from  the  very  beginning. 
It  is  observed  usually  in  the  poor,  past  middle  life,  and  is  in- 
fluenced greatly  by  continued  exposure  to  cold  and  wet  and  by 
heredity. 

Pathologic  Anatomy. — Thickening  of  the  capsule  and  liga- 
ments of  the  joints  and  the  adjacent  fibrous  structures  is  a 
marked  feature.  In  some  cases  the  cartilages  are  eroded. 
Muscular  atrophy  and  neuritis  are  observed  as  the  condition 
progresses.  These  changes  result  in  impairment  of  motion 
and  false  ankylosis. 

Symptoms. — The  principal  symptoms  are  pain  and  stiffness 
in  the  joints  aggravated  by  stormy  weather.  Tenderness  and 
slight  swelling  may  be  present  during  the  exacerbations.      In 


164  MUSCULAR   RHEUMATISM. 

most  cases  the  condition  is  polyarticular.  As  the  disease 
progresses  the  joint  movement  may  be  seriously  impaired  or 
even  lost  entirely  and  the  joints  greatly  distorted.  Except 
in  cases  attended  by  severe  pain  of  long  duration,  the  general 
health  may  not  be  seriously  impaired.  The  affection  resists 
treatment  and  tends  to  persist  indefinitely  but  does  not  en- 
danger life. 

Treatment. — The  symptoms  may  be  relieved  to  a  great  extent 
by  judicious  treatment  but  there  is  no  curative  treatment, 
lodid  of  potassium,  guaiac,  iron,  arsenic,  and  similar  tonics 
should  be  administered.  Residence  in  a  dry  and  warm  climate 
is  particularly  beneficial.  The  Turkish  bath  and  bathing  in 
the  hot  alkaline  waters  (Hot  Springs  of  Virginia  or  Arkansas) 
are  valuable. 

Locally,  counter-irritation  by  means  of  the  Paquelin  cautery, 
or  blisters,  massage,  electricity,  and  hot-air  baths  are  very 
useful.  Rubefacient  liniments  and  absorbent  ointments  may 
also  be  employed. 

MUSCULAR  RHEUMATISM. 

Synonyms. — Myalgia;  and  according  to  location:  cephalo- 
dynia;  lumbago;  torticollis;  pleurodynia. 

Definition. — An  affection  of  the  voluntary  muscles,  inflam- 
matory in  character,  either  acute  or  chronic;  characterzied  by 
pain,  tenderness,  and  stiffness  of  the  affected  muscles.  It  is 
never  complicated  with  cardiac  disease. 

Causes. — A  disease  of  adult  life.  One  attack  predisposes  to 
another.  Almost  always  due  to  cold  or  damp,  or  direct  draught 
of  cold  air.     Gout  increases  the  tendency  to  attacks. 

Pathologic  Anatomy. — The  true  nature  of  muscular  rheuma- 
tism is  not  yet  determined.  Virchow  suggests  a  "hyperemia 
of,  and  scanty  serous  exudation  between,  the  muscular  stri^, 
in  chronic  cases  inflammatory  proliferation  of  the  connective 
tissue." 

Symptoms. — The  first  attack  is  generally  acute,  and  its  onset 
is  rather  sudden  with  pain,  slight  tenderness,  and  stiffness  of 


MUSCULAR   RHEUMATISM.  1 65 

the  affected  muscles,  increased  by  any  attempt  at  movement. 
These  symptoms  may  be  constant  or  may  only  be  brought  out 
on  motion.  Spasmodic  contraction  and  rigidity  of  the  muscles 
may  be  present.  Fever  is  absent  and  there  are  no  objective 
symptoms.  The  acute  form  seldom  lasts  more  than  a  week; 
the  chronic  variety  recurs  frequently  especially  with  changes 
in  the  weather,  and  may  become  constant. 

Varieties. — It  may  affect  any  or  all  of  the  voluntary  muscles, 
but  its  most  frequent  and  important  varieties  are: 

1.  Cephalodynia. — Situated  in  the  occipito-frontal  muscles. 
Distinguished  from  neuralgia  of  the  trifacial  or  occipital  nerve, 
by  pain  on  both  sides  of  the  head,  excited  or  aggravated  by 
the  movements  of  the  muscles  and  by  absence  of  disseminated 
points  of  tenderness.  The  muscles  of  the  eye  may  be  affected, 
and  movements  of  that  organ  excite  pain.  If  the  temporal 
and  masseter  muscles  are  attacked,  mastication  induces  pain. 

2.  Torticollis. — Wry  neck,  or  stiff  neck.  Situated  in  the 
sternomastoid  muscles.  Generally  limited  to  one  side  of  the 
neck,  toward  which  side  the  head  is  twisted,  great  pain  being 
excited  on  attempting  to  turn  to  the  opposite  side.  Rheum- 
atism of  the  muscles  of  the  back  of  the  neck,  cervicodynia, 
may  be  mistaken  for  occipital  neuralgia. 

3.  Pleurodynia, — Situated  in  the  thoracic  muscles,  and 
may  be  mistaken  for  pleuritis,  or  intercostal  neuralgia,  from 
which  it  is  differentiated  by  the  absence  of  the  diagnostic 
features  of  each.  Pain  is  excited  by  forced  breathing,  coughing, 
.and  sneezing. 

4.  Lumbago  or  Lumbodynia. — Situated  in  the  mass  of 
muscles  and  fasciae,  which  occupy  the  lumbar  region.  This 
is  the  most  common  variety;  and  usually  affects  both  sides.  It 
may  set  in  rapidly,  and  become  very  severe.  Motion  of  any 
kind  aggravates  the  pain,  which  often  becomes  very  sharp  or 
stabbing  in  character.  It  is  sometimes  complicated  with  acute 
sciatica,  when  the  suffering  is  agonizing. 

Prognosis. — Death  never  results  from  this  condition.  The 
attacks  may  be  relieved  by  prompt  and  appropriate  treatment, 
but  the  rheumatic  tendency  is  often  difficult  to  eradicate. 


1 66  MUSCULAR   RHEUMATISM. 

Treatment. — Rest  is  the  first  indication.  This  is  accomplished 
in  pleurodynia  by  firmly  strapping  the  affected  side  with  broad 
strips  of  plaster,  extending  from  mid-spine  to  midsternum. 

The  local  application  to  the  affected  muscles  of  hot 
poultices,  made  of  two-thirds  pilocarpus  leaves  and  one-third 
flaxseed  meal,  changing  them  every  two  hours,  is  the  most 
rapidly  successful  treatment  in  acute  cases. 

In  all  cases,  the  internal  administration  of  antipyrin,  gr.  x  to 
XX  (0.6  to  1.3  gm.),  sodium  salicylate,  gr.  xv  to  xx  (i.  to  1.3  gm.), 
or  lithium  bromid,  gr.  v  to  xxx  (0.324  to  1.944  gm.),  every 
three  hours  is  of  great  benefit.  When  there  is  great  pain  and 
consequent  insomnia  the  following  should  be  used: 

I^.      Pulv.  ipecac,  et  opii  grx  .6  gm. 

Potass,  nitrat gr.v  to  x      .  3  to  .  6  gm. 

M.  S. — In  powder,  morning  and  night. 

Or  morphin  sulphate,  gr.  1/8  to  1/4  (0.008  to  0.016  gm.),  and 
atropin  sulphate,  gr.  1/80  (0.0008  gm.),  should  be  injected 
directly  into  the  affected  muscles  and  repeated  as  the  occasion 
requires.  When  the  disease  is  limited  to  a  few  muscles  the 
following  liniment  is  valuable : 

I^.      01  gaultheriae oiss  6.  c.c. 

Spirit,  vini  rectif f  5ij  60  .  c.c. 

M.  S. — Thoroughly  rub  into  affected  part. 

In  all  forms,  but  more  particularly  in  lumbago,  a  few  dry 
cups  or  blisters  over  the  seat  of  pain  will  afford  immediate 
relief.  Other  measures  of  value  are  dry  heat  such  as  a  warm 
fiat-iron,  hot-air  baths,  massage,  electricity,  and  acupuncture. 

In  chronic  cases,  the  administration  of  potassium  iodid, 
guaiac,  sulphur,  arsenic,  or  gelsemium  in  various  combinations 
is  recommended.  The  bowels  should  be  kept  regular,  prefer- 
ably by  the  use  of  salines.  The  local  treatment  is  similar  to 
that  of  the  acute  form,  being  modified  to  suit  the  individual 
case. 


ARTHRITIS    DEFORMANS.  1 67 

ARTHRITIS  DEFORMANS. 

Synonym . — Rheumatoi  d  arthri tis . 

Definition. — A  destructive  disease  of  the  joints,  attended  by 
destructive  changes  in  the  synovial  membranes,  cartilages,  and 
bone,  by  osseous  formations  about  the  articulations,  loss  of 
motion,  and  deformity. 

Causes. — The  etiology  is  doubtful.  It  occurs  most  often  in 
middle-aged  women.  Among  the  predisposing  causes  may  be 
mentioned  heredity,  bad  hygiene,  exposure,  injury,  prolonged 
lactation,  frequent  pregnancies,  menopause,  grief,  mental 
anxiety,  tuberculosis,  and  frequent  attacks  of  acute  articular 
rheumatism.  It  is  considered  a  trophoneurosis  by  some  ob- 
servers, and  by  others  to  be  of  infectious  origin. 

Pathologic  Anatomy. — At  first  the  affection  is  attended  by 
hyperemia  of  the  synovial  membrane  and  increase  of  the  syno- 
vial fluid.  This  is  followed  by  proliferation  of  its  cells  with  the 
subsequent  formation  of  villous  or  nodular  outgrowths.  The 
capsular  membrane  becomes  irregularly  thickened  and  the 
synovial  fluid  decreases  .  As  the  process  progresses  the  internal 
ligament  is  destroyed,  thus  permitting  dislocation.  The  inter- 
articular  fibrocartilages  become  ulcerated  and  disappear  as 
do  the  cartilages  covering  the  ends  of  the  bones,  thus  exposing 
the  articular  extremities  of  the  bones  which  become  smooth, 
eburnated,  and  greatly  enlarged.  The  villous  nodules  become 
ossified  and  the  periosteum  forms  new  bone.  The  adjacent 
ligamentous  and  fibrous  structures  become  greatly  thickened. 
Stiffness  and  impairment  of  motion  .are  produced  at  first  but 
later  ankylosis  (false),  immobility,  and  deformities  result. 
The  surrounding  muscles  atrophy  and  neuritis  is  not  infrequent. 

Symptoms. — The  affection  may  be  acute  or  chronic.  In  the 
acute  variety  several  joints  are  atacked  at  the  same  time  and 
slight  pyrexia  is  present.  The  affected  joints  are  swollen  and 
painful  but  other  acute  inflammatory  phenomena  are  absent. 
The  attack  subsides  more  or  less,  to  recur  after  a  varying  interval. 

The  chronic  form  usually  attacks  but  one  joint  at  first, 
beginning,  as  a  rule,  in  one  of  the  metacarpo-phalangeal  articu- 


1 68  ARTHRITIS    DEFORMANS. 

lations.  The  joint  slowly  enlarges  and  becomes  painful, 
neuralgic  pains  being  excited  by  any  attempts  at  movement. 
As  the  disease  progresses  the  wrists,  ankles,  elbows,  knees, 
jaws,  and  spine  are  involved,  the  corresponding  joints  on  each 
side  of  the  body  being  affected  simultaneously.  Movement  is 
greatly  impaired  and  soon  the  articulations  become  rigid. 
Crepitation  is  distinct  after  ulceration  has  destroyed  the  carti- 
lage. Redness  and  tenderness  are  absent  but  swelling  is 
marked.  The  muscles  waste,  thereby  giving  the  joints  the 
appearance  of  greater  hypertrophy.  Deformity  soon  mani- 
fests itself  due  to  the  disappearance  of  the  cartilages  and  to 
contractures  of  the  muscles.  The  fingers  are  bent  backwards 
and  drawn  toward  the  ulnar  side.  The  patient  lies  with  the 
thighs  and  legs  drawn  up  in  adduction.  Occasionally  there  is 
effusion  into  the  joints.  In  addition  to  pain  there  may  be 
tingling,  numbness,  local  sweating,  and  pigmentation  of  the 
skin.  The  disease  tends  to  advance  slowly,  ultimately  involv- 
ing all  the  joints  and  rendering  the  patient  a  helpless  invalid. 

Heberden's  nodosities  are  the  nodules,  encountered  in  this  dis- 
ease, on  the  sides  and  ends  of  the  distal  phalanges  of  the  fingers 
and  toes.  They  occur  most  often  in  middle-aged  women. 
They  may  be  the  seat  of  pain  and  tenderness,  especially  when 
the  parts  are  cold  or  injured.  Subjects  having  these  nodules 
seldom  have  invasion  of  the  large  joints.  Similar  nodules  are 
sometimes  observed  in  gout. 

Diagnosis. — Chronic  articular  rheumatism  is  often  confounded 
with  rheumatoid  arthritis;  but  the  former  lacks  the  marked 
structural  changes  and  the  progressive  involvement  of  joint 
after  joint. 

Gout  differs  from  rheumatoid  arthritis  by  the  presence  of  de- 
posits of  urate  of  sodium  in  the  joints,  the  ears,  tips  of  fingers, 
and  the  bursae  over  the  olecranon  process  of  the  elbow,  the 
presence  of  uric  acid  in  the  blood,  and  the  decided  history  of 
acute  paroxysms. 

Gonorrheal  rheumatism,,  so-called,  has  symptoms  akin  to 
rheumatoid  arthritis,  but  the  history  of  urethral  discharge 
clears  up  the  diagnosis. 


GOUT.  169 

Paralysis  agitans,  when  pronounced,  might  be  confounded 
with  rheumatoid  arthritis  if  the  examination  were  Hmited  to 
the  joints;  but  the  whole  history,  such  as  the  tremor,  the  gait, 
etc.,  should  prevent  error. 

Prognosis. — If  early  treatment  be  instituted,  the  disease  may 
be  held  in  abeyance  for  several  years.  After  pronounced 
structural  changes  have  begun,  the  malady  is  incurable,  al- 
though it  may  remain  stationary  for  a  long  time. 

Treatment. — The  diet  and  hygiene  should  receive  attention, 
and  all  measures  tending  to  improve  the  general  health  should 
be  employed.  Before  serious  structural  changes  have  occurred, 
the  rubbing  into  the  joint  of  cod-liver  oil  with  the  internal  ad- 
ministration of  effervescing  lithium  citrate,  3i  (4  gm.),  three 
times  daily  and  the  following  tonic  mixture  is  of  value : 

Py.      Massae  ferri  carbonat.  .  .  .    gr.v  .3  gm. 

Liquor",  potass,  arsenit  .  .     n^v  .  3  c.c. 

Vini    xerici f  3  j  4  •     c.c. 

Aqu«  distill f  3  j  4-     c.c. 

M.  S. — After  meals,  well  diluted. 

The  internal  administration  of  guaiacol  carbonate,  gr.  v  to  x 
(0.3  to  0.6  gm.),  three  times  daily  together,  with  painting  of 
the  joints,  when  painful,  with  the  following  is  at  times  very 
efficient : 

I^.      Guaiacol i  part. 

Tinct.  iodi 6  parts. 

M.  S. — Paint  over  joints  twice  daily. 

Iron,  arsenic,  salicylates,  etc.,  may  also  be  employed.  Mas- 
sage is  often  of  value. 

GOUT. 

Synonym. — Podagra. 

Definition. — A  constitutional  disease,  usually  inherited; 
characterized  by  the  sudden  occurrence  of  a  paroxysm  of  severe 
pain  and  swelling  in  one  of  the  smaller  joints — the  great  toe 
usually — with  the  presence  of  uric  acid  in  the  blood,  and  the 
deposit  of  the  urate   of  sodium  in  the  structure  of  the  joint. 


170  GOUT. 

When  occurring  in  the  hand,  it  has  been  termed  chiragra;  and 
when  in  the  knee,  gonagra. 

Causes. — The  attacks  usually  follow  some  dietetic  indis- 
cretion such  as  the  overindulgence  in  malt  liquors  and  sweet 
wines,  excessive  eating,  and  exposure.  Lead-poisoning,  nervous 
strain,  sedentary  habits,  and  slight  injury  are  also  causes. 
The  tendency  towards  gout  is  usually  inherited,  and  men  are 
affected  with  greater  frequency  than  women.  In  the. inherited 
variety  there  are  some  manifestations  early  in  life,  but  in  tlie 
acquired  form  it  seldom  shows  itself  before  the  age  of  thirty-five. 

Pathologic  Anatomy. — The  disease  is  believed  to  be  brought 
about  by  an  excess  of  uric  acid  in  the  blood,  salts  of  which,  par- 
ticularly the  urate  of  sodium,  are  deposited  in  the  structure  of 
the  small  joints  and  tissues  that  are  not  very  vascular.  As  these 
deposits  increase  inflammatory  reaction — hyperemia,  redness, 
swelling,  and  effusion  are  produced,  terminating  ultimately  in 
ulceration  and  expulsion  of  chalk-like  masses  of  varying  size. 
In  many  cases  the  deposits  are  retained  for  an  indefinite  period, 
becoming  greater  with  each  attack,  finally  causing  great 
deformity  and  stiffness.  The  metatarsophalangeal  joint  of 
the  great  toe  is  usually  first  affected,  but  the  deposits  also 
accumulate  in  the  knuckles,  eyelids,  and  cartilages  of  the  ear. 
Crystals  of  sodium  urate  may  be  seen  by  the  naked  eye  in  the 
tubules  and  intratubular  structure  of  the  kidneys,  which  become 
small,  granular,  and  fibrous  (gouty  kidney).  Hypertrophy 
of  the  left  ventricle  and  arteriosclerosis  usually  accompany 
or  result  from  this  condition. 

Symptoms. — Acute  gout  is  rare  in  the  United  States.  It  occurs 
in  paroxysms  between  which  are  varying  intervals.  The  parox- 
ysm is  usually  preceded,  for  a  few  days,  by  acid  dyspepsia, 
constipation,  headache,  lassitude,  insomnia,  irritability  of 
temper,  etc.  The  attack  in  most  cases  begins  suddenly,  be- 
tween midnight  and  2  a.  m.  with  acute  pain  in  the  ball  of  the 
great  toe,  which  becomes  red,  hot,  swollen,  and  so  sensitive 
that  the  slightest  touch  is  intolerable.  The  veins  are  filled, 
the  foot,  ankle,  and  leg  swollen,  and  the  limb  the  seat  of  sudden 
spasmodic   contractions,    which   increase   the    suffering;    slight 


GOUT.  171 

relief  is  afforded  by  elevating  the  limb.  Associated  with  the 
local  symptoms  are  chill,  fever,  quickened  pulse,  thirst,  coated 
tongue,  constipation,  and  scanty,  acid,  high-colored  urine, 
which  deposits,  on  cooling,  a  heavy  brickdust  sediment.  To- 
ward daylight  the  symptoms  ameliorate  to  return  again  at 
sundown,  the  severity  gradually  lessening  until  the  fourth  or 
fifth  day,  when  convalescence  is  established,  the  patient,  as  a 
rule,  feeling  better  than  before  the  attack. 

Rctrocedent  gout  is  the  term  used  to  indicate  those  cases  in 
which  the  symptoms  suddenly  disappear  in  the  joints  and  are 
followed  by  alarming  gastric,  cardiac,  or  cerebral  manifestations. 

Chronic  gout  results  from  a  repetition  of  acute  attacks,  and 
in  typical  cases  the  deposits  may  be  detected  in  the  various 
regions  in  which  they  are  prone  to  occur  with  stiffness  and 
varying  grades  of  deformity  in  the  smaller  joints.  Constitu- 
tional symptoms  are  present,  but  to  a  milder  degree.  Parox- 
ysms are  apt  to  occur  at  any  time,  but  develop  slowly  with  less 
pronounced  symptoms. 

Diagnosis. — The  history,  mode  of  life,  age,  acute  onset,  loca- 
tion, and  the  presence  of  the  deposits  (tophi)  will  serve  to  dis- 
tinguish the  affection  from  acute  articular  rheumatism  and 
rheumatoid  arthritis,  with  which  it  may  at  times  be  confounded. 
The  following  table  from  Gould  and  Pyle's  Cyclopedia  of  Medi- 
cine will  also  help : 

Gout.  i  Rheumatism. 


1.  Chiefly  affects  small  joints.  i.   Affects  larger  joints. 

2.  More  pain,  redness,  and  edema.        2.  Parts  swollen  but  less  pain- 

ful. 

3.  Moderate  fever — 101°.  3.   High  fever — 104°. 

4.  Sweats  not  profuse.  j  4.   Profuse   acid   sweats. 

5.  Pain  more  periodic.  1  5.   Pain  continuous. 

6.  Cuticle  desquamates.  j  6.   Cuticle  usually  intact. 

7.  Often  recurs  at  regular  intervals,  i  7.    Time    of   recurrence    indefi- 

nite. 


172  GOUT. 

Prognosis. — Acute  gout  is  rarely  fatal,  but  is  prone  to  recur. 
Chronic  gout  is  less  favorable.  The  kidney,  arterial,  and  cardiac 
complications  materially  shorten  life.  Acute  diseases  or  in-, 
juries  occurring  in  the  course  of  chronic  gout  are  more  serious 
than  under  other  circumstances. 

Treatment. — In  the  acute  attack,  wine  of  colchicum  root,  gtt. 
XV  to  XXX  (i  to  2  cc),  well  diluted,  should  be  given  immediately 
and  repeated  every  two  hours  until  relief  is  afforded  or  the 
physiologic  limit  reached.  It  may  be  combined  with  sodium 
salicylate,  gr.  xx^(i.3  gm.),  every  two  hours.  The  bowels 
should  be  opened  by  the  administration  of  a  course  of  calomel, 
followed  by  a  saline.  Water,  especially  the  alkaline  waters, 
should  be  freely  consumed.  The  diet  should  be  liquid,  prefera- 
bly milk.      Bartholow  recommends  the  following  pill: 

I^.     Colchicinae gr.  1/140  .0013  gm. 

Ext.  colocynth.  comp.  .  .    gr.  ss  .032     gm. 

Quininae  sulphat g^"-  iij  -2         gm. 

M.     Ft.  pil.  No.  i. 

S. — One  such  pill  to  be  taken  every  three  hours. 

The  pain  will  call  for  the  use  of  the  coal-tar  products  and 
morphin,  but  the  latter  should  be  used  with  caution  on  account 
of  the  possible  kidney  complications.  The  affected  part  should 
be  elevated  and  dressed  with  cloths  soaked  in  lead-water  and 
laudanum. 

For  subacute  or  lingering  cases  potassium  iodid,  alone  or  in 
combination,  as  the  following,  is  of  value : 

I^.     Potassii  iodidi 3ij  8 .  gm. 

Vini  colchici  radicis f  5iv  15  .  cc. 

Aquae  destil f  oiiss  75  .  cc. 

M.  S. — Teaspoonful,  well  diluted,  after  meals  and  at  bed- 
time. 

In  chronic  gout  the  diet,  habits,  mode  of  life,  etc.,  should  be 
subjected  to  considerable  regulation.  As  far  as  practicable  all 
nitrogenous  or  albuminous  substances  should  be  interdicted. 
The  patient  should  be  forbidden  pastry,  hot  bread,  cakes,  sweet- 


LITHEMIA.  173 

meats,  spices,  condiments,  veal,  liver,  mutton,  lamb,  pork, 
cheese,  tomatoes,  beans,  oatmeal,  sugar,  tea,  coffee,  wines,  and 
malt  liquors.  The  foods  permissible  include  milk,  butter,  oys- 
ters, fish,  vegetables,  and  acid  fruits,  such  as  strawberries, 
lemons,  and  oranges. 

The  free  use  of  water,  particularly  alkaline  waters,  such  as 
Buffalo  lithia,  Farmville  lithia,  or  Saratoga  vichy,  should  be 
encouraged.  The  administration  of  effervescing  citrate  of 
lithium,  5i  (4  gm.),  in  water  three  times  daily,  and  of  the  saline 
laxatives  is  also  of  value.  The  underclothing  should  be  woolen, 
and  it  is  advisable  for  the  patient  to  seek  a  residence  in  a  warm 
climate.  Exercise  and  massage  are  of  great  importance  in  the 
treatment.  Hydrotherapeutic  measures — cold  bathing,  Turkish 
bath,  etc. — when  cautiously  employed,  are  of  great  value. 

The  medicinal  treatment  includes  the  use  of  the  alkaline  car- 
bonates, colchicum,  salicylates,  potassium  iodid,  guaiac,  and 
tonics,  such  as  iron,  quinin,  strychnin,  and  arsenic. 

LITHEMIA. 

Synonyms. — Lithiasis;  uric  acid  diathesis;  uricemia;  American 
gotit. 

Definition. — A  condition  in  which  the  fluids  of  the  body  are 
saturated  with  nitrogenized  waste,  in  the  form  of  uric  (or  lithic) 
acid;  characterized  by  marked  dyspepsia,  various  nervous 
phenomena,  muscular  and  articular  pains,  bronchial  catarrh, 
all  or  any  of  these  associated  with  scanty,  high-colored,  acid 
urine. 

Causes. — High  living,  with  little  exercise,  sedentary  habits,  im- 
perfect digestion  of  nitrogenous  food,  and  impaired  elimination 
of  uric  acid  are  the  principal  causes.  The  direct  or  remote 
offspring  of  gouty  individuals  are  the  most  frequent  subjects. 

Pathology. — The  pathology  is  not  well-defined.  The  affec- 
tion is  believed  to  be  due  to  faulty  elimination  of  certain  waste 
products  which  have  a  deleterious  influence  on  the  nervous 
system. 

Symptoms. — Coated  tongue,  fetid  breath,  more  or  less  loss  of, 


174  LITHEMIA. 

or  alteration  in  the  appetite,  dyspepsia,  flatulence,  abdominal 
distress  and  constipation  are  common  manifestations.  The 
urine  is  scanty,  high-colored,  and  acid  in  reaction.  The 
specific  gravity  is  about  1024  to  1028.  Sugar  and  albumin  are 
absent,  but  urates,  uric  acid  crystals,  and  oxalates  are  present 
in  large  quantities.  The  urine  is  irritating  and  gives  rise  to 
pains  in  the  loins  and  burning  sensation  in  the  urethra  during 
its  passage.  Various  nervous  symptoms  may  be  encountered, 
such  as  depression  of  spirits,  impaired  memory,  sleeplessness, 
vertigo,  headache,  neuralgia,  irritability  of  temper,  ringing  in 
the  ears,  and  a  constant  dread  of  apoplexy  or  other  cerebral 
diseases.  Neuralgic  pains  in  the  joints,  in  the  dorso-lumbar 
region,  and  in  the  right  scapular  region,  are  common.  The 
second  aortic  sound  becomes  accentuated,  and  there  is  increased 
arterial  tension.  Various  cutaneous  affections,  urticaria,  ery- 
thema multiforme,  erythema  nodosum,  etc.,  may  occur  as  mani- 
festations of  this  condition. 

Complications. — When  the  affection  persists  for  a  long 
period  untreated,  chronic  interstitial  nephritis,  fatty  heart, 
enlargement  of  the  liver,  arteriosclerosis,  chronic  bronchitis, 
or  angina  pectoris  may  supervene  as  complications. 

Diagnosis. — The  history,  the  course,  and  the  absence  of  well- 
marked  joint  symptoms  serve  to  distinguish  it  from  gout  and 
rheumatism. 

Prognosis. — The  disease  is  essentially  chronic,  but  when 
properly  treated  recovery  is  to  be  expected,  otherwise  the 
affection  becomes  serious  through  its  complications. 

Treatment. — Regulation  of  the  diet  is  the  first  indication. 
The  quantity  of  food  consumed  should  be  greatly  reduced. 
Fresh  meat  should  be  eaten  but  once  daily,  and  the  diet  list 
should  be  made  up  largely  of  milk,  skimmed  milk,  milk  and 
cream,  poultry,  game  (plainly  cooked),  fresh  fish,  oysters, 
occasionally  eggs,  lettuce,  spinach,  celery,  cold  slaw,  and  toma- 
toes. All  kinds  of  starchy  and  saccharine  foods,  fats,  stimu- 
lants, tea,  and  coffee  should  be  interdicted.  Systematic  exer- 
cise is  of  great  importance.  Water,  especially  the  alkaline 
mineral  waters,   should  be  freely  employed.     Care  should  be 


2  . 

•   gm 

2  . 

c.c. 

6. 

c.c. 

RICKKTS.  175 

taken  to  avoid  the  use  of  tonics,  bromids,  chloral,  or  (jpium 
in  the  treatment.  Saline  laxatives  should  be  administered, 
followed  by  intestinal  antiseptics,  such  as  salol,  gr.  v  (0.32  gm.), 
three  times  daily,  or  potassium  permanganate,  gr.  i  (0.065  gi^-). 
after  meals. 

Good  results  follow  the  use  of  lithium  citrate,  gr.  xx  (1.3  gm.), 
three  times  daily,  sodium  phosphate,  gr.  xxx  to  Ix  (2  to  4  gm.), 
three  times  daily,  or  benzoic  acid,  gr.  x  (0.6  gm.),  three  times 
daily.  One  of  the  best  drugs  in  this  condition  is  dilute  nitric 
acid,  nxx  (0.6  c.c),  in  half  a  glass  of  water  four  times  daily,  with 
the  occasional  use  of  compound  rhubarb  pill  at  bed-time. 
Considerable  benefit  is  at  times  derived  from  piperazin,  gr. 
x  to  XV  (0.6  to  I  gm.),  in  solution  after  meals,  and  also  from 
strontium  in  combination: 

I^.      Strontii  bromidi gr.  xxx 

Glycerini n|xxx 

Infus.  gentianae f  oiss 

M.  S. — Before  meals,  well  diluted. 


RICKETS. 

Synonym. — Rachitis. 

Definition. — A  nutritional  disease  occurring  in  early  child- 
hood and  characterized  by  changes  in  structure  of  the  bones, 
with  consequent  deformity,  muscular  weakness,  and  nervous 
disturbances. 

Causes, — The  affection  usually  develops  in  the  early  months  of 
the  second  year,  although  in  rare  instances  it  may  be  congenital. 
"Among  the  important  etiologic  factors  may  be  mentioned 
negro  race,  foul  air,  insufficient  or  improper  food,  lack  of  sun- 
light, dampness,  poverty,  and  city  life.  Syphilis  may  be  a 
cause  in  some  cases. 

Pathologic  Anatomy. — The  structural  changes  are  most 
marked  in  the  bones  of  the  skull,  the  long  bones,  and  the  ribs. 
The  head  assumes  a  box-shape,  due  to  enlargement  of  the  parie- 
tal and  frontal  eminences  and  flattening  of  the  occiput  and  top 


76  RICKETS. 

of  the  head.  The  fontanels  often  remain  open  until  the  second 
or  third  year.  In  the  long  bones,  the  cartilages  between  the 
epiphysis  and  shaft  become  swollen  and  spongy  in  structure. 
The  periosteum  is  thickened  and  by  its  proliferation  spongy 
tissue  is  also  formed.  The  affected  parts  show  a  marked  defi- 
ciency in  lime  salts.  The  bones  are  consequently  soft  and  bend 
easily,  giving  rise  to  deformities  such  as  bow-legs,  knock-knees, 
pigeon-breast,  curvature  of  the  spine,  etc.  Green-stick  frac- 
tures are  not  uncommon  results.  The  chondral  ends  of  the 
ribs  become  enlarged  and  nodular,  giving  the  breast  a  beaded 
appearance  (rachitic  rosary).  Chemical  examination  of  the 
diseased  bones  shows  an  increase  in  the  percentage  of  organic 
matter  with  a  marked  diminution  in  the  proportion  of  inorganic 
or  mineral  constituents.  The  liver,  spleen,  and  sometimes  the 
mesenteric  glands  are  enlarged. 

Symptoms. — In  addition  to  the  various  changes  in  shape  in 
the  head,  chest,  and  long  bones,  there  may  also  be  present 
restlessness  and  feverishness  at  night,  with  profuse  perspiration 
about  the  head,  di'ffuse  tenderness,  nausea,  vomiting,  abdominal 
distention,  slight  diarrhea,  nervousness,  convulsions,  etc. 
Dentition  is  delayed  and  when  the  teeth  do  appear  they  are 
badly  formed.  Muscular  weakness  is  marked  and  prevents  the 
child  from  walking  or  even  sitting  up  (pseudo-paralysis). 

Com.plications. — The  profound  weakness  predisposes  to  all  the 
various  affections  of  childhood.  The  most  common  complica- 
tions are  bronchial  catarrh,  bronchopneumonia,  atelectasis, 
chronic  hydrocephalus,  diarrhea,  laryngismus  stridulus,  and 
convulsions. 

Prognosis. — The  disease  is  not  fatal  in  itself,  but  may  become 
serious  in  the  presence  of  complications.  Deformities  are 
common  sequels,  and  in  the  case  of  the  female  pelvis  may  be  of 
grave  importance  in  subsequent  labors. 

Treatm.ent. — The  first  indications  are  to  place  the  child  in 
hygienic  surroundings  and  to  provide  proper  food.  If  the  child 
is  nursing  and  the  mother's  milk  is  poor,  cow's  milk  should  be 
substituted  and  properly  modified  to  suit  the  individual  re- 
quirements.     Older  children  should  be  given  beef-juice,  eggs, 


HEMOPHILIA.  177 

and  beef  peptonoids,  in  addition  to  milk.  Starches  and  sugars 
should  be  avoided.  Orange  and  lemon  juice  are  beneficial  in 
many  cases.  Thin  gruels  may  be  used.  Cod-liver  oil,  syrup 
of  iodid  of  iron,  hypophosphite  of  calcium,  lactophosphate 
of  calcium,  lime-water,  and  phosphorous,  are  the  drugs  usually 
employed  in  this  condition. 

HEMOPHILIA. 

Synonyms. — Hemorrhagic     diathesis;     "bleeder's     disease." 

Definition. — A  congenital  condition  characterized  by  a  tend- 
ency to  uncontrollable  hemorrhages,  with  or  without  abra- 
sions. 

Cause. — Heredity  is  the  most  prominent  etiologic  factor. 
Males  are  most  often  affected,  but  the  disease  is  transmitted 
by  females. 

Symptoms. — The  bleeding  appears  about  the  period  of  first 
dentition,  and  consists  of  spontaneous  hemorrhages  from  the 
mucous  membrane  of  the  nose,  mouth,  lungs,  stomach,  intes- 
tines, and  genitourinary  passages,  or  in  typical  cases  hemor- 
rhages occur  directly  from  the  fingers,  toes,  lobes  of  the  ears, 
back  of  the  hands  or  arms,  without  any  apparent  change  in 
skin,  and  continue,  in  spite  of  treatment,  for  days  or  wrecks. 
Traumatic  hemorrhages  occur  if  an  injury  of  any  kind  is  sus- 
tained about  the  period  of  the  development  of  the  bleeding. 
Epistaxis  is  common.  Attacks  of  arthritis  with  fever  frequently 
occur. 

Prognosis. — The  condition  usually  terminates  fatally  before 
puberty.  Death  rarely  occurs  in  the  first  bleeding.  The 
younger  the  individual  at  the  time  of  the  development  of  the 
disease  the  more .  unfavorable  is  the  prognosis.  The  hemor- 
rhagic tendency  may  be  outgrown. 

Treatment. — Internally,  the  administration  of  potassium 
chlorate,  tincture  of  the  chlorid  of  iron,  and  ergot  are  believed 
to  favorably  influence  the  condition.  Locally,  pressure,  ice, 
heat,  gelatin,  tannic  acid,  gallic  acid,  calcium  chlorid,  fibrin 
ferment,  adrenalin  chlorid,  etc.,  may  be  employed. 
12 


178  SCORBUTUS. 

SCORBUTUS. 

Synonyms. — Scurvy;  scorbutic  purpura. 

Definition. — A  peculiar  condition  of  malnutrition  or  anemia, 
characterized  by  great  debility,  mental  lethargy,  hemorrhages 
of  the  skin  and  from  the  mucous  membranes,  and  a  swollen 
and  spongy  condition  of  the  gums  which  tend  to  bleed  on  the 
slightest  irritation. 

Causes. — A  deficiency  of  fresh  vegetables  in  the  diet,  and  un- 
hygienic surroundings  are  the  most  common  factors  in  its  produc- 
tion. Mental  depression,  home-sickness  (nostalgia),  and  similar 
disturbances  also  seem  to  influence  the  condition.  It  occurs 
most  often  in  sailors  of  the  merchant  marine,  in  prisons,  in 
armies,  and  where  large  bodies  of  men  are  collected  under  un- 
sanitary conditions.  By  some  observers  the  disease  is  con- 
sidered infectious. 

Pathologic  Anatomy. — The  blood  is  dark  and  fluid,  and  its 
composition  deranged  with  diminution  in  the  potassium  salts. 
Anemia  is  present  but  there  is  no  increase  in  the  white  blood 
cells.  The  structure  of  the  blood-vessels  is  altered,  allowing 
spontaneous  hemorrhages  into  the  skin,  muscles,  joints,  and 
internal  organs  and  from  the  mucous  membranes.  There  is 
swelling  and  ulceration  of  the  gums  often  resulting  in  loss  of 
the  teeth.  Ulcers  of  the  ileum  and  colon  may  be  encountered. 
The  spleen  is  enlarged  and  soft,  and  the  viscera  are  affected 
with  parenchymatous  changes. 

Symptoms. — The  onset  is  slow,  with  general  weakness,  lassi- 
tude, indisposition  to  mental  or  physical  exertion,  and  anemia. 
The  skin  is  rough,  dry,  and  of  a  muddy  pallor  and  the  face  is 
pale  and  bloated.  The  gums  soon  become  swollen  and  spongy 
and  may  present  a  fungoid  appearance.  They  tend  to  bleed 
on  the  slightest  irritation.  The  teeth  loosen  and  may  fall  out. 
The  breath  is  extremely  offensive.  The  lips  are  pale  and  the 
eyes  are  sunken  and  surrounded  by  dark  blue  circles.  There  is 
marked  depression  of  spirits.  Palpitation  of  the  heart  and  dys- 
pnea follow  slight  exertion.  Petechial  hemorrhages  of  the 
skin  and  bleeding  from  the  various  mucous  surfaces  are  com- 


SCORBUTUS.  179 

mon.  Brawny  induration  of  the  muscles  is  often  observed. 
Edema  of  the  face  and  ankles  is  not  infrequent.  Pain,  tenderness, 
and  swelling  of  the  joints  may  be  present.  Various  visual  dis- 
turbances may  occur.  Fever  is  absent  except  in  the  late  stages 
and  in  the  presence  of  complications.  Constipation  is  common. 
The  urine  is  high-colored,  of  increased  density,  and  contains 
an  increase  of  phosphates  and  often  blood. 

Infantile  sctirvy  (Barlow's  disease)  is  a  cachectic  condition 
occurring  in  young  children  as  the  result  of  improper  feeding, 
usually  following  the  long-continued  use  of  proprietary  foods, 
condensed  milk,  etc.  Prostration,  anemia,  and  general  de- 
bility are  marked.  In  the  beginning  the  child  lies  with  the  legs 
drawn  up  and  immobile,  any  attempt  to  move  them  inducing 
pain  and  consequent  crying;  they  are  not  tender  at  this  stage, 
but  soon  ill-defined  swellings  appear  on  the  lower  extremities 
and  extreme  tenderness  is  manifest.  The  limbs  are  now  everted 
and  immobile  (pseudoparalysis).  Weakness  becomes  pro- 
found and  hemorrhagic  extravasations  may  be  noted.  Epi- 
physeal fractures  are  common.  The  sternum  and  adjacent 
cartilages  appear  depressed  and  localized  thickening  of  the 
various  bones  of  the  body  may  be  observed.  Prolapse  of  one 
eyeball,  pufhness  of  the  upper  lid,  and  subconjunctival  ec- 
chymoses  are  not  infrequent. 

Complications. — Dysentery,  typhoid  fever,  or  typhus  fever 
may  exist  coincidently. 

Prognosis. — Recovery  is  the  rule,  both  in  adults  and  infants, 
when  the  appropriate  treatment  is  instituted  early  in  the 
course  of  the  disease. 

Treatment. — The  patient  should  be  removed  to  sanitary 
quarters  and  fresh  vegetables  added  to  the  diet.  The  principal 
antiscorbutic  substances  are  raw  cabbage,  cresses,  potatoes, 
sauerkraut,  onions,  lemon-juice,  oranges,  and  various  fruits. 
These  should  be  employed  in  conjunction  with  meats,  milk,  and 
farinaceous  foods.  In  the  infantile  form  the  artificial  feedings 
should  be  properly  adjusted  by  the  attending  physician  and  in 
addition  orange-juice  should  be  administered.  In  all  forms 
the  mouth  should  be  thoroughly  cleansed  with  mild  antiseptic 


l8o  PURPURA. 

and  astringent  lotions.  Iron,  quinin,  strychnin,  and  the  bitter 
tonics  may  be  necessary  to  stimulate  the  appetite  and  combat 
the  exhaustion. 

PURPURA. 

Synonym. — Morbus  maculosus  Werlhofii. 

Definition. — An  acute  disease,  characterized  by  purplish 
discolorations  of  the  skin,  the  result  of  hemorrhages  into  the 
upper  layers  of  the  cutis  beneath  the  epidermis.  When  the 
purpuric  spots  are  tiny,  like  a  pin-point,  they  are  termed 
petechice;   when   larger    in    size,    they    are    termed   ecchymoses. 

Varieties. — Purpura  simplex;  purpura  hcemorrhagica;  purpura 
urticans;  peliosis  rheufnatica. 

Causes." — The  etiology  is  obscure.  The  disease  occurs  most 
frequently  in  debilitated  individuals.  In  many  cases  it  is 
secondary  to  some  other  affection,  but  it  also  occurs  as  a  pri- 
mary condition.  By  some  observers  it  is  believed  to  be  of  in- 
fectious origin. 

Symptoms. — Purpura  simplex  is  the  mildest  form  of  the 
affection  and  is  characterized  by  the  sudden  appearance  of 
small,  bright  red  spots — a  cutaneous  hemorrhage — most  com- 
monly on  the  legs,  coming  in  crops,  associated  with  slight 
lassitude,  mild  febrile  reaction,  and  aching  pains  in  the  limbs. 
The  hue  of  the  spots  rapidly  fades  to  a  purplish  color  and  they 
slowly  disappear.      Relapses  are  common. 

Purpura  hcFmorrhagica  has,  in  addition  to  the  eruption  of 
purpura  simplex — the  cutaneous  hemorrhage,  a  flow  of  blood 
from  the  free  surface  of  mucous  membranes.  The  most  common 
hemorrhage  is  epistaxis,  slight  or  profuse.  Other  hemorrhages 
are  hematemesis,  melena,  hematuria,  hemoptysis,  menorrhagia, 
and  also  into  the  substance  of  the  mucous  membranes  of  the 
palate,  cheek,  and  gums.  This  variety  is  associated  with  great 
debility  and  depression,  moderate  fever,  and  disorders  of 
digestion.      Marked  anemia  results  from  the  hemorrhages. 

Purpttra  urticans  is  a  combination  of  urticaria  and  purpura 
simplex.  It  is  characterized  by  rounded  and  reddish  eleva- 
tions  of   the   cuticle,    resembling   wheals,    but   which   are   not 


PURPURA.  l8l 

accompanied,  like  the  wheals  of  urticaria,  by  any  sensation  of 
itching  or  tingling.  They  are  usually  situated  on  the  legs, 
thighs,  breast,  and  arms,  and  are  interspersed  with  petechiae. 
They  form  gradually  and  subside  within  twenty-four  or  thirty- 
six  hours.  Relapses  are  frequent.  This  variety  is  also  asso- 
ciated with  malaise,  moderate  fever,  and  pains  in  the  limbs. 

Peliosis  rheumatica  (Schonlein's  disease)  is  characterized 
by  multiple  arthritis  and  a  purpuric  eruption;  frequently  the 
arthritic  symptoms  are  associated  with  urticaria  or  with  ery- 
thema exudativum.  Edema  is  often  marked,  as  are  also  the 
fever,  sore-throat,  and  general  constitutional  symptoms.  The 
eruption  is  sometimes  of  vesicles — pemphigoid  purpura. 

Diagnosis. — Purpuric  spots  may  be  distinguished  from  other 
lesions  of  the  skin  by  their  failure  to  entirely  disappear  on 
pressure.  The  concomitant  symptoms  will  serve  to  separate 
the  several  varieties  and  to  distinguish  the  disease  from  scurvy 
and  hemophilia. 

.  Prognosis. — The  prognosis  of  purpura  simplex  and  purpura 
urticans  is  favorable,  but  relapses  are  very  frequent.  Purpura 
hemorrhagica  is  always  a  grave  disease,  often  proving  fatal  from 
exhaustion,  or,  more  rarely,  from  cerebral  or  pulmonary  hemor- 
rhage. Peliosis  rheumatica  is  often  a  severe  affection,  but 
recovery  is  the  rule. 

Treatment. — Rest  in  bed  with  the  administration  of  a  con- 
centrated nutritious  diet,  tonics,  and  stimulants  is  necessary 
when  there  is  much  depression.  Mild  cases,  rheumatic  in 
origin,  do  well  with  the  use  of  the  salicylates  and  potassium 
iodid.  In  marked  cases,  arsenic,  dilute  sulphuric  acid,  tincture 
of  the  chlorid  of  iron,  ergot,  silver  nitrate,  digitalis,  quinin, 
turpentine,  and  similar  remedies  will  be  required.  The  follow- 
ing formula  may  be  employed: 

I^.      01.  terebinthinae f  3ij  8.  c.c. 

01.  amygdalae  express  ..  .   foj  30.  c.c. 

Tinct.  opii  deodorat f  5ss  2  .  c.c. 

Mucil  acaciae f  5j  30.  c.c. 

Aq.  lauro-cerasi  .q.  s.  ad  f  oiij  ad  90.  c.c. 

M.  S.— One  tablespoonful  every  three  hours,  diluted. 


152  DIABETES    MELLITUS. 

DIABETES  MELLITUS. 

Synonyms. — Glycosuria;  melituria. 

Definition. — A  chronic  disorder  of  metabolism  characterized 
by  the  constant  presence  of  grape-sugar  in  the  urine,  an  ex- 
cessive urinary  discharge,  and  the  progressive  loss  of  flesh  and 
strength. 

Causes. — The  specific  cause  of  this  condition,  and  its  exact 
nature,  are  both  unknown.  The  affection  is  most  commonly 
observed  in  males,  most  often  in  Hebrews  between  the  ages  of 
twenty-five  and  fifty  years.  It  is  rare  in  negroes.  Among  the 
most  important  etiologic  factors  may  be  mentioned  inherited 
tendency,  disorders  of  the  nervous,  hepatic,  and  renal  systems, 
excessive  use  of  farinaceous  foods  and  malt  liquors,  sedentary 
habits,  mental  anxiety,  and  sexual  excesses. 

Pathology. — The  disease  is  believed  to  be  due  primarily  to 
some  disturbance  of  the  pancreas,  the  adrenals,  pituitary,  thy- 
roid, or  the  nervous  system.  Experimental  puncture  of  the 
floor  of  the  fourth  ventricle  has  produced  it,  as  has  also  disease 
and  extirpation  of  the  pancreas.  In  a  large  proportion  of  cases 
it  is  possible  to  demonstrate  changes  in  the  pancreas,  but  more 
frequently  hyperemia  and  hypertrophy,  sometimes  degener- 
ation, of  the  liver  and  kidneys  may  be  observed.  The  patho- 
genesis is  extremely  obscure.     There  are  no  constant  lesions. 

Symptoms. — Clinically,  cases  differ  greatly  in  their  course  and 
severity;  one  class  presenting  slight  symptoms  and  a  chronic 
course;  another  class  having  marked  local  and  constitutional 
symptoms  and  running  an  acute  course.  The  symptoms  of  a 
typical  case  may  be  arranged  under  the  following  heads : 

Urinary  Symptoms. — Micturition  is  frequent  and  accompanied 
by  pain  in  the  region  of  the  kidneys.  The  urine  is  greatly 
increased  in  quantity  (4,  8,  12,  20,  or  even  30  pints  in  twenty- 
four  hours).  It  is  pale,  clear,  and  watery,  having  a  sweetish 
taste  and  odor.  The  specific  gravity  ranges  from  1025  to  1050. 
It  ferments  rapidly  if  kept  in  a  warm  place.  Sugar  is  present 
in  amounts,  varying  from  an  ounce  to  2  pounds  in  twenty-four 
hours.     The  urea  and  uric  acid  are  increased.     Albumin  may 


DIABETES    MELLITUS.  183 

be  present.  The  increased  passage  of  a  large  quantity  of 
saccharine  urine  causes  a  constant  itching,  burning,  and  un- 
easy sensation  at  the  prepuce,  along  the  urethra,  and  at  the 
neck  of  the  bladder;  in  females,  itching  and  eczema  of  the  vulva 
are  common;  in  children,  incontinence  of  urine  is  frequent. 

Digestive  Symptoms . — Thirst  is  almost  constant,  and  the 
mouth  is  dry  and  parched.  The  breath  may  have  a  sweetish 
odor  and  the  tongue  is  irritable,  beefy  red,  and  often  cracked. 
The  appetite  is  variable,-  at  times  excessive,  at  others,  absent. 
Vomiting  occasionally  occurs.  Dyspeptic  symptoms  are  com- 
mon. Constipation,  with  pale  and  dry  stools,  is  the  rule,  but 
diarrhea  may  occur. 

General  Symptoms. — The  patient  complains  of  feeling  very 
weak  and  languid,  and  of  soreness  and  pains  in  the  limbs. 
Emaciation  soon  becomes  marked.  The  skin  is  harsh,  dry, 
and  often  intensely  itchy.  The  countenance  assumes  a  dis- 
tressed and  worn  expression.  Various  nervous  phenomena 
make  their  appearance.  Mental  changes  are  often  noticed; 
depression  of  spirits;  decline  in  firmness  of  character  and  moral 
tone;  and  irritability  are  present.  Neuralgia  and  headache  are 
common.  Sexual  inclination  and  power  are  greatly  dimin- 
ished. Visual  defects  are  not  infrequent.  The  temperature 
is  usually  below  normal.  The  heart's  action  is  weak,  with  a 
frequent  low-tension  pulse.  The  blood  and  various  secretions 
contain  sugar. 

Complications. — The  principal  cutaneous  complications  are 
boils,  carbuncles,  pruritus,  eczema,  and  gangrene,  especially 
of  the  feet  and  legs.  The  pulmonary  complications  of  greatest 
frequency  are  tuberculosis,  lobar  pneumonia,  and  gangrene. 
The  most  common  eye  complications  are  cataract,  retinitis, 
optic  atrophy,  palsies,  and  toxic  amblyopia.  The  nervous 
complications  include  peripheral  neuritis,  ringing  in  the  ears, 
deafness,  and  diabetic  coma  or  acetonemia,  a  condition  char- 
acterized by  unconsciousness,  dyspnea,  pain  in  the  head, 
delirum,  rapid  and  feeble  pulse,  sweetish  odor  of  the  breath, 
and  the  presence  of  acetone  in  the  urine.  Nephritis  may  also 
occur  as  a  complication. 


184  DIABETES   MELLITUS. 

Course. — In  most  instances  the  course  is  chronic,  lasting 
for  years,  the  symptoms  beginning  insidiously  and  becoming 
progressively  worse,  with,  at  times,  decided  remissions.  Oc- 
casionally the  disease  runs  an  acute  course,  death  occurring 
within  four  or  five  weeks. 

Diagnosis. — Diabetes  mellitus  only  exists  when  grape-sugar 
is  permanently  present  in  the  urine.  "  It  is  not  the  quantity, 
but  the  persistence  of  sugar  which  constitutes  diabetes."  With 
grape-sugar  in  the  urine,  associated  with  more  or  less  increase 
in  the  urinary  flow,  it  should  be  mistaken  for  no  other  affection. 

It  may  be  distinguished  from  Bright' s  disease  by  the  absence  of 
dropsy  and  of  tube-casts  in  the  urine,  and  the  constant  presence 
of  sugar  in  the  urine ;  but  the  amount  of  albumin  in  the  urine  is 
never  so  great  or  constant  in  diabetes  mellitus  as  in  Bright' s 
disease. 

From  diabetes  insipidus  it  may  be  separated  by  the  presence  of 
sugar  in  the  blood  and  urine  and  by  the  larger  quantity  of 
urine  voided  in  diabetes  insipidus. 

Simple  glycosuria  differs  from  diabetic  glycosuria  in  that  the 
amount  of  sugar  in  the  urine  is  not  constant — at  one  time  being 
present,  at  another  absent — the  amount  of  urine  voided  is 
never  in  excess  of  health;  simple  glycosuria  is  a  disease  of  the 
aged;  diabetic  glycosuria  usually  appears  under  fifty  years. 
Simple  glycosuria  often  results  from  the  inhalation  of  chloro- 
form, the  excessive  use  of  chloral,  and  as  one  of  the  results  of 
injuries  to  the  head.  It  may  occur  from  excitement  and  in  the 
insane. 

Prognosis. — The  majority  of  cases  ultimately  prove  fatal 
from  gradual  exhaustion  or  from  profound  blood-poisoning, 
ending  in  diabetic  coma  or,  rarely,  uremia.  The  complications 
are  often  the  direct  cause  of  death.  Amelioration  of  the  symp- 
toms may  occur  and  the  progress  of  the  malady  may  be  greatly 
retarded  with  treatment.  Complete  recovery  seldom,  if  ever, 
occurs.  The  younger  the  patient  the  more  rapid  is  the  course 
of  the  disease.  Surgical  operations  should  not  be  undertaken 
in  diabetic  patients  on  account  of  the  tendency  to  gangrene. 

Treatment. — The  treatment    of    diabetes    may  be  conveni- 


DIABETES    MELLITUS.  '  185 

ently  considered  under  three  headings:  dietetic,  hygienic,  and 
medicinal. 

Dietetic  Treatment. — The  diet  should  be  so  regulated  as  to 
exclude  or  at  least  to  reduce  to  a  minimum  the  quantity  of 
starches  and  sugars.  The  patient  should  be  allowed  to  partake 
of  meats  of  every  kind,  soups  made  with  meat  and  without 
flour,  game,  poultry,  fish,  oysters,  lobsters,  crabs,  eggs,  butter, 
cheese,  oils,  fats,  cream,  buttermilk,  milk,  spinach,  celery,  let- 
tuce, cabbage,  tomatoes,  asparagus  tops,  water-cress,  string- 
beans,  onions,  cucumbers,  pickles,  olives,  unsweetened  jellies,- 
almonds,  walnuts,  butternuts,  filberts,  apples,  lemons,  straw- 
berries, tea  and  coffee  without  sugar,  claret.  Burgundy,  and 
Rhine  wines,  carbonated  waters,  and  bread  made  from  gluten, 
bran,  or  almond  flour.  * 

The  substances  which  should  be  especially  denied  the  patient 
are  ordinary  bread  or  flour,  sugar,  honey,  potatoes,  parsnips, 
peas,  barley,  beans,  rice,  tapioca,  arrowroot,  cracked  wheat, 
oatmeal,  turnips,  beets,  corn,  carrots,  prunes,  grapes,  figs, 
bananas,  pears,  peaches,  watermelons,  canteloupes,  chestnuts, 
chocolate,  biscuits,  pastry,  syrups,  preserves,  sweet  wines,  and 
malt  liquors. 

When  sweetening  of  the  food  is  absolutely  necessary,  sac- 
charin or  glycerin  may  be  used  for  that  purpose. 

Hygienic  Treatment. — Fresh  air,  daily  bathing,  and  regular 
exercise  are  essential  to  the  treatment.  Perfect  ventilation  of 
the  apartment  in  which  the  patient  works  and  sleeps  is  highly 
important.  The  use  of  various  mineral  waters  is  very  beneficial. 
The  exercise  should  be  taken  daily  and  regulated  according  to 
the  patient's  strength,  being  careful  to  avoid  overexertion 
Flannel  underclothing  should  be  constantly  worn. 

Medicinal  Treatment. — A  great  number  of  drugs  are  recom- 
m.ended  for  this  condition,  most  of  which  are  useless.  The 
most  valuable  drug  is  opium  or  one  of  its  derivatives.  Codein, 
gr.  ss  to  iii  (0.032  to  0.2  gm.),  three  times  daily,  gradually  in- 
creasing the  dose,  is  the  alkaloid  most  commonly  employed. 
Morphin  hydrochlorid,  gr.  i  (0.065  gm.)  daily,  or  powdered 
opium,  gr.  iii  to  v  (0.2  to  0.3  gm.)  daily,  may  be  used  instead. 


1 86  DIABETES   MELLITUS. 

The  constipation  which  these  preparations  are  prone  to  produce 
should  be  combated  by  the  use  of  the  natural  aperient  waters, 
such  as  Hunyadi,  Carlsbad,  Vichy,  etc.  Arsenic,  in  the  form 
of  Fowler's  solution,  is  especially  valuable  in  this  disease.  Ergot 
and  ammonium  carbonate  are  also  employed  at  times  with 
benefit.  Uranium  nitrate,  gr.  iii  (0.2  gm.)  three  times  daily, 
and  sodium  salicylate,  gr.  xv  (i.  gm.)  three  times  daily,  will 
often  lessen  the  quantity  of  urinary  secretion  and  reduce  the 
amount  of  sugar.  The  bromids  are  efficient  in  controlling  the 
nervous  symptoms;  potassium  or  sodium  bromid,  3i  (4  gm.)  in 
twenty-four  hours,  or  the  solution  of  the  bromid  of  arsenic, 
niiii  to  V  (0.2  to  0.3  c.c.)  three  times  daily,  may  be  employed. 
The  alkalies,  and  especially  the  alkaline  carbonates  and  alkaline 
mineral  waters,  are  of  especial  value.  The  coal-tar  prod- 
ucts, antipyrin,  acetanilid,  and  phenacetin,  in  doses  of  gr. 
X  to  XV  (0.6  to  I  gm.)  three  times  daily,  combined  with  an  equal 
quantity  of  sodium  bicarbonate  will  be  found  very  sufficient 
in  some  cases  of  mild  type.  Powdered  jambul  seeds,  gr.  v  to  x 
(0.3  to  0.6  gm.)  three  times  daily,  and  methylene  blue,  gr.  viii 
(0.52  gm.)  daily,  have  been  used  with  success.  Among  other 
drugs  used  in  this  condition  may  be  mentioned  pepsin,  iodin, 
potassium  iodid,  lactic  acid,  glycerin,  quinin,  tincture  of  can- 
nabis indica,  cod-liver  oil,  and  adrenalin.  The  galvanic  cur- 
rent is  sometimes  of  value.  The  emaciation  calls  for  the  use  of 
tonics  in  addition  to  the  remedies  employed  to  combat  the 
disease.  The  sleeplessness  and  unrest  require  morphin,  bro- 
mids, chloral,  or  hyoscin  hydrobromid.  The  excessive  thirst 
may  be  greatly  relieved  by  the  following: 

I^.     Potassii  phosphat 2  parts. 

Aquse 75  parts. 

M.    S. — One  teaspoonful  twice  01    thrice  daily,  in  wine   or 
hop  tea. 

Diabetic  coma  requires  inhalations  of  oxygen,  subcutaneous 
injections  of  sodium  carbonate,  and  hypodermoclysis  and 
enteroclysis.  The  alkaline  treatment  is  regarded  as  a  preven- 
tive measure  in  this  complication. 


DIABETES    INSIPIDUS.  187 

DIABETES  INSIPIDUS. 

Synonym. — Polyuria. 

Definition. — An  affection  characterized  by  the  excessive  secre- 
tion of  a  very  large  quantity  of  pale,  watery  urine,  free  from 
albumin  and  sugar. 

Causes. — The  affection  may  be  inherited  or  diabetes  mellitus 
may  have  existed  in  the  parent.  It  is  most  often  observed  in 
children  and  young  adults.  Men  are  more  liable  than  women. 
Injuries,  tumors,  and  diseases  of  the  nervous  system,  hysteria, 
exposure  to  cold,  consumption  of  excessive  quantities  of  cold 
water,  fatigue,  prolonged  debility,  malaria,  syphilis,  and  intense 
emotional  excitement  may  help  to  produce  the  condition.  The 
probable  immediate  cause  of  the  excessive  secretion  of  urine 
consists  in  dilatation  of  the  renal  vessels,  the  result  of  paralysis 
of  their  muscular  coat,  caused  by  derangement  of  innervation, 
since  the  condition  can  be  induced  experimentally  by  irritating 
a  certain  area  in  the  fourth  ventricle,  or  by  section  of  portions 
of  the  sympathetic  nerve. 

Symptoms. — The  affection  is  characterized  by  great  thirst, 
with  an  increased  flow  of  pale,  watery,  slightly  acid  urine,  the 
amount  varying  from  one  to  five  or  six  gallons  in  the  twenty- 
four  hours.  The  specific  gravity  ranges  from  i.ooi  to  1.007. 
Sugar  and  albumin  are  absent.  Urea  and  the  other  solids  are  in- 
creased. The  appetite  is  voracious,  the  bowels  are  obstinately 
constipated,  and  the  skin  is  dry  and  harsh.  The  large  flow 
of  urine  is  usually  preceded  by  various  nervous  phenomena,  as 
nervousness,  irritability,  inability  to  concentrate  the  mind,  vivid 
imagination,  a  failure  of  memory,  and  headache.  Unless  the 
affection  is  soon  arrested,  great  loss  of  flesh  and  strength  result. 

Diagnosis. — It  differs  from  diabetes  mellitus  by  the  absence  of 
grape-sugar  in  the  urine. 

From  paroxysmal  diuresis,  by  the  presence  of  the  increased 
urine  permanently. 

From  interstitial  nephritis,  by  the  greater  amount  of  urinary 
discharge  and  the  absence  of  albumin,  edema,  and  casts,  and  the 
cardiac  and  vessel  changes. 


1 88  ALCOHOLISM. 

Prognosis. — Rather  unfavorable  as  to  a  radical  cure,  unless 
caused  by  syphilis..  Death  rarely  is  due  to  the  diabetes  in- 
sipidus, but  to  some  intercurrent  malady  which  the  patient  has 
been  unable  to  withstand,  on  account  of  the  weakness  produced 
by  the  diabetes.      Spontaneous  cure  occasionally  occurs. 

Treatment. — Restriction  of  the  fluids  has  no  effect  on  the 
disease.  Ergot,  pilocarpin,  opium,  gallic  acid,  potassium 
bromid,  sodium  salicylate,  and  valerian  have  been  used  with 
varying  degrees  of  success.  In  cases  of  syphilitic  origin,  mer- 
cury and  potassium  iodid  should  be  employed.  Constipation 
should  be  avoided  by  the  administration  of  compound  cathartic 
pills.  Tonics,  such  as  iron,  quinin,  arsenic,  strychnin,  etc., 
should  also  be  given  to  maintain  the  general  health.  The 
following  formula  is  productive  of  great  benefit  in  this  disease: 

I^.      Strychnirice  sulphatis  .  .  .    gr.  1/48  -0015  gm. 

Acid,  hydrochlor.  dil.  .  .  .     n^x  ,6         c.c. 

Aquae  lauro-cerasi f  5ij  8 .  c.c. 

M,   S. — To  be  taken  three  times  daily  in  water. 

Galvanism,  applying  one  pole  to  the  neck  below  the  occiput, 
the  other  to  the  hypochondriac  region,  is  also  of  value.  Warm 
clothing,  warm  baths,  friction,  fresh  air,  exercise,  etc.,  are  useful 
adjuncts  to  the  treatment. 


THE  INTOXICATIONS  AND  SUNSTROKE. 

ALCOHOLISM. 

Varieties. — Acute  alcoholism;  chronic  alcoholism. 

Synonyms. — Acute  variety,  temulentia;  mania-a-potu. 

Chronic  variety,  delirium  tremens;  dipsomania,  or  oinomania. 

It  would  hardly  be  correct  to  consider  these  terms  interchange- 
able ;  they  are  rather  names  applied  to  various  conditions  due  to 
acute  or  chronic  alcoholic  poisoning. 

Definition. — Alcoholism  is  the  term  used  to  designate  the 
physical  and  mental  phenomena  induced  by  the  use  of  alcohol. 


ALCOHOLISM.  1 89 

Alcohol,  under  certain  conditions,  is  a  poison;  but  it  becomes  a 
much  more  dangerous  one  when  associated  with  the  various 
toxic  products  which  are  added  to  flavor  it. 

Temulentia  refers  to  drunkenness,  or  alcoholic  intoxication; 
manta-a-potu  is  an  acute  mental  derangement,  occurring  in  alco- 
holics of  strong  neurotic  tendencies;  delirium  tremens  is  an  at- 
tack of  delerium  associated  with  tremors  in  persons  with  the 
numerous  changes  resulting  from  chronic  alcoholism.  De- 
lirium tremens  frequently  results  in  alcoholics  having  one  of 
the  forms  of  nephritis,  preventing  the  elimination  of  some 
poison  developed  from  the  ingested  alcohol.  •  Dipsomania,  or 
oinomania,  is  an  alcoholic  insanity  in  which  an  individual  at 
longer  or  shorter  intervals  has  paroxysms  of  alcoholic  desires, 
between  which  he  neither  wishes  nor  craves  alcohol. 

Causes. — The  predisposing  causes  are  influences  arising  from 
unfavorable  moral,  social,  and  personal  conditions,  and  heredity. 

The  exciting  cause  is  immoderate  use  of  alcoholic  beverages, 
of  which  there  are  three  groups:  (i)  spirits,  or  distilled  liquors; 
(2)  wines,  or  fermented  liquors,  and  (3)  malt  liquors. 

Pathologic  Anatomy. — AciUe  Alcoholism.  The  brain  is  the 
seat  of  an  active  hyperemia ;  the  mucous  membrane  of  the  stom- 
ach and  duodenum  is  markedly  injected  and  covered  with  a 
ropy  mucus  slightly  tinged  with  blood,  and  the  gastric  juice  is 
altered  in  quality  and  quantity.  The  kidneys  are  also  the  seat 
of  an  active  hyperemia. 

Chronic  Alcoholism.  In  this  condition  there  are  no  organs  or 
tissues  which  do  not  present  morbid  changes.  The  gastro- 
intestinal .  mucous  membrane  presents  the  changes  of  chronic 
catarrhal  inflammation;  the  liver,  the  first  organ  to  receive  the 
poison  after  the  stomach,  shows  congestion,  cirrhosis,  or  fatty 
degeneration;  the  kidneys  show  chronic  congestion  and  often  the 
changes  incident  to  chronic  interstitial  nephritis.  The  muscular 
structure  of  the  heart  may  undergo  fatty  degeneration  and  the 
vessels,  the  changes  of  senility.  The  brain-structure  presents 
the  changes  of  sclerosis  in  various  stages,  and  there  may  be 
chronic  meningitis  and  pachymeningitis  with  hematoma.  The 
nerves  are  altered,  atrophied,  and  hardened,  and  the  neuroglia. 


190  ALCOHOLISM. 

vessels,  and  ganglion  cells  of  the  spinal  cord  show  similar 
changes. 

Symptoms. — Acute  alcoholism,  resulting  from  the  use  of  a 
large  quantity  of  alcoholic  fluid,  occurs  with  the  symptoms 
varying  from  mild  intoxication  to  drunkenness,  passing  to 
acute  delirium  and  acute  coma.  The  condition  begins  with  a 
period  of  exhilaration,  passing  to  semi-delirium  and  ending  in 
an  acute  coma,  when  the  breathing  is  stertorous,  the  face 
bloated  and  congested,  the  lips  swollen  and  purplish,  the  pupils 
contracted  or  dilated,  the  pulse  feeble  and  slow,  the  skin  cold 
and  clammy,  the  temperature  depressed,  and  frequently  con- 
trol of  sphincters  lost.  An  individual  so  affected  is  said  to  be 
"  dead  drunk.'' 

Cases  of  ordinary  drunkenness  do  not  often  pass  beyond  the 
stage  of  exhilaration,  ending  in  a  mild  coma  or  sleep. 

Mania-a-potu,  or  acute  alcoholic  delirium,  is  the  direct  result 
of  alcoholic  excess  in  those  engaged  in  a  sudden  debauch,  or  who 
have  drunk  alcoholic  beverages  very  "hard"  for  a  compara- 
tively short  period.  The  individuals  grow  more  and  more 
excitable,  lose  all  desire  for  food,  are  unable  to  sleep,  become 
the  prey  of  horrible  hallucinations — ''the  horrors" — finally 
terminating  in  mania  which  resembles  delirium  tremens  in  all 
save  the  tremor,  which  is  absent. 

Delirium  Tremens.  In  the  majority  of  instances,  delirium  re- 
sults in  a  chronic  drinker,  from  a  prolonged  debauch,-  with 
abstinence  from  proper  food.  It  begins  by  an  increased  tremor, 
insomnia,  irritable,  excited  manner,  followed  by  the  characteris- 
tic hallucinations  and  illusions,  during  which  snakes  and  other 
forms  of  repulsive  reptiles  are  seen,  causing  the  most  intense 
horror  and  abject  fear;  it  is  a  busy  delirium,  the  patient  being 
unable  to  remain  quiet.  There  also  occur  illusions  of  smell 
and  hearing.  This  marked  excitement  is  followed  by  great 
depression,  the  skin  is  cold  and  clammy,  the  pulse  feeble,  the 
muscular  system  weak,  the  mind  in  a  condition  of  coma- vigil, 
and,  if  continued,  a  febrile  condition,  typhoid  in  character,  with 
stupor  or  coma,  develops.  Uremic  symptoms  frequently  com- 
plicate the  condition,  the  temperature  suddenly  bounding  to 


ALCOHOLISM.  I91 

103°,  104°  or  105°  F.,  with  albumin  and  casts  in  the  scanty 
urine. 

The  ordinary  duration  of  an  attack  of  delirium  tremens  is 
about  two  weeks  in  those  who  recover,  although  death  may 
occur  at  any  time  from  cardiac  failure,  uremia,  or  alcoholic 
pneumonia.  Indeed,  patients  sometimes  die  suddenly  after 
the  beginning  of  apparent  improvement.  Convalescence  dates 
from  the  beginning  of  refreshing  sleep,  the  patient  awakening 
with  a  clear  mind  and  desire  for  food.  Should  the  delirium 
subside,  but  the  patient  continue  to  mutter  and  pick  at  the 
bed-clothing,  the  tongue  become  dry  and  cracked,  and  the 
regurgitation  of  dark  brownish  and  bilious  matter  occur,  the 
condition  is  critical  and  an  early  fatal  termination  may  be 
expected. 

Dipsomania,  or  oinomania,  is  the  inherited  or  acquired  mental 
condition  which  craves  the  drinking  of  intoxicating  liquors. 
This  is  a  true  mental  disease.  It  manifests  itself  in  periodic 
attacks  of  excessive  indulgence  in  alcoholic  drinking,  or  this 
symptom  of  the  sad  disease  may  be  replaced  by  other  irresistible 
desires  of  an  impulsive  kind,  such  as  lead  to  the  commission  and 
repetition  of  various  crimes,  the  gratification  of  other  depraved 
appetities,  robbery,  or  even  homicide.  Imbecility  and  demen- 
tia frequently  result. 

The  paroxysms  at  first  occur  at  long  intervals,  but  gradually 
the  intervals  become  shorter  and  shorter  until  the  individual 
entirely  surrenders  himself  to  alcoholic  and  other  excesses. 

Chronic  Alcoholism.  The  condition  to  which  this  term  has 
been  given  is  truly  a  disease.  It  is  the  result  of  the  continued 
use  of  alcoholic  beverages  until  one  or  more  of  the  morbid 
organic  changes  have  occurred.  These  persons  are  markedly 
dyspeptic,  with  coated  tongue,  fetid  breath,  and  early  morning 
vomiting,  straining,  or  retching,  attended  with  much  distress. 
There  is  a  gradually  developing  muscular  tremor,  progressing 
to  the  ataxic  gait.  Insomnia  or  restless  sleep  is  frequent. 
The  face  may  either  become  pallid,  flabby,  and  bloated,  with  an 
imbecile  expression,  or  swollen,  rough,  and  dusky,  with  great 
bladders   under   the   eyes,    and   yellow,    injected   conjunctivae. 


192  ALCOHOLISM. 

There  are  headache,  vertigo,  and  attacks  of  hallucinations; 
the  memory  grows  weaker,  the  judgment  less  accurate,  the 
moral  sense  blunted,  and  the  will-power  weak  and  erratic. 
These  and  many  other  symptoms  add  to  the  distress  of  the 
individual,  which  he  attempts  to  overcome  by  the  use  of  more 
and  more  of  the  poison. 

Diagnosis. — Profound  drunkenness,  or  alcoholic  coma,  may 
be,  and  often  is,  confounded  with  apoplectic  and  uremic  coma. 
Von  Wedekind  suggests  the  following  method  for  diagnosing 
drunkenness :  "  By  simply  pressing  on  the  supraorbital  notches 
with  a  steadily  increasing  force  one  may,  with  certainty  of 
success,  bring  an  unconscious  alcoholic  to  his  senses,  and  thus 
differentiate  between  alcoholic  and  other  comas." 

The  symptoms  of  chronic  alcoholism  often  bear  a  close  resem- 
blance to  the  following  maladies:  General  paralysis,  dissemi- 
nated sclerosis,  paralysis  agitans,  locomotor  ataxia,  cerebral 
and  spinal  softening,  epilepsy,  dementia  chronica,  and  nervous 
dyspepsia. 

In  individuals  whose  habits  are  secret,  the  question  of 
diagnosis  is  attended  with  considerable  difficulty.  Anstie  lays 
much  stress  upon  the  importance  of  the  following  four  points, 
diagnostic  of  chronic  alcoholism:  insomnia,  morning  vomiting, 
muscular  tremor,  and  causeless  'hnental  restlessness. 

Prognosis. — In  acute  alcoholism  the  prognosis  is  good  if  the 
patient  is  manageable. 

In  chronic  alcoholism  the  organic  changes,  the  direct  result 
of  the  alcoholic  habit,  tend  to  shorten  life  by  the  production  of 
fatty  heart,  Bright's  disease,  insanity,  epilepsy,  melancholia, 
and  organic  brain  diseases.  The  danger  in  delirium  tremens  is 
heart  failure  or  deepening  coma.  The  association  of  chronic 
nephritis  with  delirium  tremens,  perhaps  its  cause,  must  always 
be  taken  into  account  in  determining  a  prognosis.  Acute  lobar 
pneumonia  is  a  very  fatal  complication  in  all  forms  of  alcoholism. 

Treatment.- — In  deciding  upon  a  plan  of  medication  for  any  of 
the  varieties  of  alcoholism  the  condition  of  the  kidneys,  heart, 
and  vessels  must  be  considered.  The  treatment  of  a  case  of 
ordinary  drunkenness  requires  little  consideration,  as  the  rapid 


ALCOHOLISM.  1 93 

elimination  of  the  alcohol  soon  occurs  if  its  ingestion  be  stopped. 
The  contents  of  the  stomach  should  be  immediately  removed 
by  the  stomach-tube  or  by  the  hypodermic  injection  of  apomor- 
phin,  gr.  i/io  (0.0066  gm.).  If  the  attack  is  not  sufficiently 
severe  to  warrant  these  procedures,  fractional  doses  of  calomel 
every  half  hour  followed  by  a  saline  will  be  of  great  benefit. 
The  solution  of  ammonium  acetate  in  large,  frequently  repeated 
doses  greatly  assists  in  the  elimination  of  the  poison.  When 
the  excitement  is  extreme,  chloral,  gr.  xv  to  xxx  (i  to  2  gm.), 
should  be  given.  Morphin  is  of  great  value  in  many  of  these 
cases,  but  the  presence  of  any  kidney  complication  is  a  contra- 
indication for  its  use.  Aromatic  spirits  of  ammonia  is  also  of 
value  in  this  condition. 

For  the  collapse  following  a  lethal  dose  of  alcohol,  the  stom- 
ach should  be  immediately  emptied  by  emetics  or  the  stomach- 
tube,  and  the  organ  washed  out  with  warm  water  or  coffee,  the 
patient  placed  in  the  recumbent  position,  and  surrounded  with 
artificial  warmth,  and  hot  frictions  applied  to  the  lower  ex- 
tremities. Resort  should  be  had  to  artificial  respiration  or 
the  use  of  faradism  to  the  thorax,  inhalations  of  ammonia, 
and  hypodermic  injections  of  strychnin  sulphate,  nitroglycerin, 
digitalis,  strophanthus,  or  atropin  sulphate.  Tapping  of  the 
precordial  region  with  a  hot  spoon  (Corrigan's  hammer)  may 
serve  also  to  stimulate  the  flagging  heart. 

For  mania-a-potu,  the  immediate  and  complete  witholding 
of  alcoholic  beverages  is  essential  for  its  successful  treatment. 
The  patient  should  be  quieted  as  soon  as  possible.  The  rest- 
lessness, insomnia,  delirium,  and  visual  and  auditory  hallucina- 
tions are  usually  controlled  with  chloral,  and  on  account  of 
the  gastric  torpor  and  catarrh,  interfering  with  the  prompt 
absorption  of  medicaments,  is  best  given  by  the  bowel: 

I^.     Chloral gr.  xx  to  xxx       i .  3  to  2  gm. 

Infus.  digitalis f  §j  30.  c.c. 

M.  S. — Repeat  in  two  hoiirs,  in  milk. 

If  for  any  reason  an  enema  is  impracticable,  chloral  or 
trional,  gr.  xxx  (2  gm,),  should  be  given  by  the  mouth,  or  hy- 

13 


194  ALCOHOLISM. 

podermic  injections  of  morphin  sulphate,  gr.  1/4  to  1/3  (0.016 
to  0.022  gm.),  combined  with  atropin  sulphate,  gr.  i/ioo 
(0.00065  gm.),  or hyoscin hydrobromid,  gr.  i/ioo  (0.00065  gi^-). 
may  be  employed.  Chloralose,  gr.  v  to  x  (0.33  to  0.66  gm.), 
and  paraldehyd,  f  5ss  to  i  (2  to  4  c.c),  may  also  be  used.  Physi- 
cal restraint  may  be  required.  An  attack  of  acute  alcoholism, 
or  mania-a-potu,  may  often  be  aborted  with  trional,  gr.  xxx 
(2  gm.),  repeated  in  two  hours,  or  chloralamid,  gr.  xxx  to  xl 
(2  to  2.6  gm.),  repeated.  Excellent  and  prompt  results  follow 
the  use  of  a  hot-air  bath  until  profuse  sweating  occurs. 

If  one  or  two  medicinal  doses  of  the  selected  sedative  drug 
do  not  produce  quiet  and  sleep,  be  most  cautious  in  repeating, 
remembering  that  the  patient  is  suffering  from  the  depressing 
effects  of  a  cardiac  and  nerve  poison,  which  is  best  combated 
by  eliminating  action  on  skin,  bowels,  and  kidneys,  and  the 
administration  of  food.  If  the  attack  be  associated  with  symp- 
toms of  cardiac  depression,  resort  to  brisk  friction,  hot  alcohol 
and  water  sponging,  artificial  warmth,  stimulating  enemata, 
and  the  hypodermic  administration  of  strychnin  sulphate,  gr. 
1/20  to  1/30  (0.003  "to  0.002  gm.),  repeated,  or  citrated  caffein, 
gr.  iij  (0.2  gm.),  or  digitalis. 

The  general  nutrition  should  be  given  attention,  as  in  most 
cases  it  will  be  found  that  the  patient  has  had  very  little  food 
for  several  days.  If  the  stomach  will  tolerate  food— and 
usiially  it  will — milk  diluted  with  liquor  calcis  or  Seltzer  water, 
or  hot  beef-tea,  strongly  seasoned  with  capsicum,  should  be 
administered'every  hour  or  two  in  small  amounts. 

The  appetite  is  stimulated  by  the  use  of  the  following: 

I^.     Tin ct.  nucis  vomicae.  ..  .     f5iv  15.  c.c. 

Tinct.  capsici f  oiv  15  .  c.c. 

Tinct.  cinchonae  comp   .  .    f  §ij  60.  c.c. 

M.  S. — One  teaspoonful,  diluted,  every  two  or  three  hours. 

This  stomachic  stimulant  may  be  alternated  with  aromatic 
spirits  of  ammonia,  f5j  (4  c.c),  given  in  hot  milk,  with  ad- 
vantage to  the  heart  and  nervous  system.  The  bowels  should 
be  moved  at  once  by  the  administration  of  an  enem^; 


ALCOHOLISM.  195 

1^.      Magnesii  sulphat oij  ^)o .  gm. 

Glycerini f  §j  30.  c.c. 

Aquae  bul fSiv  120.  c.c. 

M.  S.  — Use  as  directed. 

The  kidneys  should  be  stimulated  by  full  doses  of  spirits  of 
nitrous  ether  if  the  patient  is  able  to  swallow,  and  if  not,  by  the 
hypodermic  injection  of  citrated  cafTein. 

In  delirium  tremens,  the  patient  should  be  isolated  and  placed 
under  the  care  of  a  skillful,  sensible  nurse.  The  alcohol  may 
be  entirely  withdrawn  or  its  quantity  greatly  reduced.  Tyson 
advises  complete  withdrawal  of  the  poison,  combating  any 
resulting  adynamia  with  ammonia,  digitalis,  and  strychnin, 
The  stomach  should  be  washed  out  daily  and  an  easily  digested 
diet  should  be  supplied.  A  free  action  of  the  skin,  kidneys, 
and  bowels  should  be  obtained  as  soon  as  possible  to  effect 
elimination  of  the  poisonous  products  retained  in  the  system. 
The  excitability  of  the  nervous  system  should  be  controlled 
by  nerve  sedatives.  For  this  purpose,  hypodermic  injections  of 
morphin  sulphate,  gr.  1/4  (0.016  gm.),  combined  with  atropin 
sulphate,  gr.  i/ioo  (0.00065  g™-)>  or  hyoscin  hydrobromid, 
gr.  i/ioo  (0.00065  gm.),  or  chloral  or  trional  by  the  mouth  or 
rectum  are  especially  applicable.  When  the  stomach  is  not 
too  irritable  the  following  will  be  found  of  value : 

I^.      Chloral oiv  15.  gm. 

Tr.  capsici f  3ij  8  .  c.c. 

Aquae  menth.  pip.  q.  s.  ad  f  §vj  ad  180.  c.c. 

M.  S. — Tablespoonful  every  two  hours  until  sleep,  alter- 
nated with  a  cup  of  hot  beef-tea,  to  which  has  been  added  a 
bolus  of  capsicum,  gr.  xx  (1.3  gm.). 

Care  should  be  taken  not  to  produce  coma  by  these  remedies. 
Not  more  than  two  doses  in  six  hours  should  be  allowed  but  in- 
stead push  the  administration  of  hot  liquid  diet  and  atropin  sul- 
phate, gr.  1/64  (o.ooi  gm.),  with  strychnin  nitrate,  gr.  1/32 
(0.002    gm.),    hypodermically,   as  experience  has  proven  that 


196  ALCOHOLISM. 

these  drugs  given  three  times  daily  in  reducing  doses,  are  the 
physiologic  antidotes  to  the  alcoholic  poison. 

When  the  depression  and  cardiac  weakness  are  great,  strych- 
nin sulphate,  citrated  caffein,  spirits  of  chloroforrn,  ammo- 
nium carbonate,  strophanthus,  and  digitalis  are  of  value. 
Atony  of  the  stomach  requires  lavage  and  the  administration 
of  the  previously  mentioned  capsicum  mixture.  When  for  any 
reason  the  nerve  sedatives  already  advised  are  contra-indicated, 
paraldehyd,  chloralamid,  or  the  bromids  may  be  employed. 
Strict  attention  must  be  given,  at  all  times,  to  the  condition 
of  the  skin,  bowels,  and  kidneys.  If  the  heart  is  not  much 
depressed,  the  cautious  use  of  the  hot-air  bath  or  the  hypo- 
dermic injection  of  pilocarpin  hydrochlorid,  gr.  1/3  (0.02  gm.), 
repeated  at  the  onset  of  the  mania  -will  be  found  of  great 
value. 

Chronic  Alcoholism.  The  combination  of  symptoms  termed 
chronic  alcoholism  are  the  direct  result  of  the  continuous  action 
of  a  poison,  and  no  success  of  even  a  temporary  kind  can 
be  expected  unless  the  poison  be  withdrawn.  The  rapidity 
with  which  this  can  be  accomplished  is  a  question  for  the  skill, 
judgment,  and  experience  of  the  physician  to  determine;  the 
chief  obstacle  to  its  success  will  be  found  to  be  moral  rather 
than  physical.  Next  to  the  disuse  of  alcohol  is  the  question  of 
diet.  Progress  will  be  made  as  the  appetite  and  digestion  im- 
prove, and  great  attention  should  be  given  to  these.  The 
general  health  will  also  be  benefited  by  fresh  air,  exercise, 
mental  occupation,  and  cold  or  tepid  sponging  and  an  occa- 
sional hot  bath  at  bedtime.  For  the  combination  of  symptoms 
of  spirit-craving,  morning  vomiting,  muscular  tremor,  mental 
restlessness,  and  insomnia,  no  drug  is  comparable  with  strych- 
nin nitrate,  either  hypodermically  twice  daily,  or,  what  is 
preferable,  by  the  stomach  to  secure  its  local  action  on  the 
mucous  membrane.  If  the  insomnia  be  persistent  in  spite  of 
the  foregoing  treatment,  the  temporary  use  may  be  made  of 
such  remedies  as  chloral,  morphin  sulphate,  paraldehyde,  or 
trional.  In  many  cases  it  is  desirable,  for  its  mental  effect, 
if  no  other,  to  administer  what  the  patient  terms  a  substitute 


PELLAGRA.  I 97 

for  his  alcoholic  beverages.     The  following  is  a  good  combina- 
tion for  that  purpose : 

I^.      Tincturae  nucis  vomicae .  .    f5ss  15.  c.c. 

Tincturae  capsici f§ss  15.  c.c. 

Fluidext.    lupulini fSiij  90.  c.c. 

Inf.  gent,  comp f  5ij  60  .  c.c. 

M.    S. — Dessertspoonful    three    or  four    times    daily,    well 
diluted. 

For  the  anemia,  loss  of  strength,  and  mental  debility,  benefit 
may  follow  the  use  of  syrup  of  hypophosphites  with  strychnin. 

Dipsomania.  The  management  of  these  cases  is  much  the 
same  as  has  already  been  mentioned  for  chronic  alcoholism, 
although  the  strychnin  sulphate  treatment  should  be  given  the 
preference. 

PELLAGRA. 

.  Definition. — An  endemic  or  epidemic  disease,  characterized  by 
nervous,  gastric,  and  cutaneous  symptoms,  and  whose  cause 
is  unsettled. 

Etiology. — Middle  age,  unsanitary  surroundings,  unwholesome 
food,  and  the  spring  months  of  the  year  seem  to  be  predisposing 
factors.  The  laboring  class  is  chiefly  attacked.  The  actual 
cause  is  said  to  be  maize;  and  "  the  morbific  action  of  maize  has 
been  variously  attributed  to — 

(a)    Deficiency  in  its  nutritive  principles. 

ih)   Specific  toxic  substance  contained  normally  in  the  grain. 

{c)  Poisons  elaborated  after  it  has  been  ingested. 

{d)  Toxic  substances  elaborated  during  decomposition  of  the 
grain. 

{e)  Fungi  or  bacteria  found  on  maize"      (Manson). 

Symptoms. — Languor,  debility,  and  disinclination  to  work  are 
prodromata.  Pallor,  headache,  pain  in  back  and  joints,  giddi- 
ness, coated  tongue,  epigastric  pain  or  tenderness,  constipation, 
or  bloody  diarrhea,  are  then  noted.  This  is  followed  or  accom- 
panied by  an  erythema  on  face,  neck,  chest,  back  of  hands  and 
feet,  and  forearms  and  legs.     This  lasts  two  weeks,  and  leaves 


198  HEAT    STROKE. 

the  skin  rough.  Nervous  symptoms  are  present,  such  as  ex- 
aggerated reflexes,  tongue,  tremor,  insomnia,  melancholia. 

Improvement  may  follow,  but  exacerbations  occur.  The 
prognosis  is  not  very  good. 

Treatment  consists  in  the  internal  administration  of  arsenic 
and  liberal  and  nutritious  diet. 

HEAT  STROKE. 

Synonyms. — Insolation;  sunstroke;  thermic  fever;  coup-de- 
soleil ;  heat  exhaustion. 

Definition. — A  depression  of  the  vital  powers,  the  result  of 
exposure  to  excessive  heat.  The  condition  manifests  itself  as 
acute  meningitis  (rare)  heat  exhaustion  (common),  and  as  true 
sunstroke. 

Causes. — Exposure  to  the  influence  of  excessive  heat,  either  to 
the  direct  rays  of  the  sun  or  artificial  heat  in  confined  quarters, 
or  diffused  atmospheric  heat  without  proper  ventilation. 

Among  the  predisposing  causes  which  act  by  lessening  the 
power  of  the  system  to  resist  the  heat  are  great  bodily  fatigue, 
overcrowding,  and  intemperance. 

Pathologic  Anatomy. — The  action  of  the  heat  upon  the  system 
is  so  sudden,  and  the  malady  so  rapid  in  its  course,  that  struc- 
tural changes  seldom  develop.  The  left  ventricle  is  firmly 
contracted  (Wood).  The  right  heart  and  vessels  are  engorged 
with  dark  fluid  blood.  All  the  tissues  and  organs  of  the  body 
are  in  a  state  of  great  venous  congestion.  The  blood  is  dark, 
thin,  and  either  feebly  alkaline  or  decidedly  acid,  and  its  co- 
agulability is  destroyed.  The  post-mortem  rigidity  is  early  and 
marked. 

Symptoms. — These  depend  upon  the  variety  of  the  affection. 

Acute  meningitis,  the  result  of  exposure  to  heat,  has  symp- 
toms similar  to  those  of  cases  due  to  other  causes. 

Heat  exhaustion  develops  with  a  rapid  feeling  of  weakness  and 
prostration,  the  surface  is  cool,  the  face  pale,  the  voice  weak, 
the  pulse  rapid  and  feeble,  the  respiration  increased,  the  vision 
grows  dim  and  indistinct,  noises  develop  in  the  ears,  the  individ- 


HEAT   STROKE.  1 99 

ual,   overcome,   becomes    partially  or  completely  unconscious.' 
In  some  cases  the  attack  of  prostration  is  sudden,  the  person 
falling  unconscious,  with   perhaps   convulsions  or  tremors  and 
shrunken  features. 

Sunstroke  develops  suddenly,  with  or  without  prodromes,  and 
is  manifested  by  insensibility  with  or  without  delirium,  convul- 
sions, or  paralysis,  flushed  and  hot  body-surface,  injected  con- 
junctivae, rapid  and  shallow  or  labored  and  stertorous  breathing, 
quick  pulse  either  bounding  or  weak,  and  an  axillary  tempera- 
ture ranging  from  105°  to  108°  to  110°  F.,  with  suppression  of 
all  glandular  action.  When  death  occurs  it  results  from  as- 
phyxia or  from  slow  failure  of  respiration  and  the  circulation. 

Diagnosis. — It  is  of  great  importance,  therapeutically,  to 
distinguish  at  once  between  attacks  of  sunstroke  and  heat 
exhaustion.  This  may  be  readily  done  by  the  aid  of  a  ther- 
mometer. Cases  of  sunstroke  are  to  be  differentiated  from 
cerebral  hemorrhage  and  alcoholic  insensibility  by  the  history, 
season,  occupation,  and  by  the  temperature. 

Prognosis. — Attacks  of  heat  exhaustion,  if  properly  and 
promptly  treated,  are  favorable.  The  prognosis  of  sunstroke, 
or  heat-fever,  is  unfavorable  in  the  majority  of  cases,  death 
resulting  in  from  half  an  hour  to  several  hours.  Unfavorable 
indications  are  increased  temperature,  cardiac  failure,  convul- 
sions, and  absent  reflexes,  followed  by  complete  muscular 
relaxation. 

Favorable  indications  are  decline  in  surface  heat  and  axillary 
or  rectal  temperature,  stronger  pulse,  increased  depth  of  respira- 
tions, restored  reflexes,  and  return  of  consciousness. 

Sequels. — In  any  form  of  this  affection  one  or  more  of  the  fol- 
lowing conditions  may  result:  headache,  vertigo,  insomnia,  epi- 
lepsy, mental  enfeeblement,  and  monoplegia,  paraplegia,  or 
hemiplegia. 

Treatment. — In  heat  exhaustion,  the  patient  should  be  placed 
in  the  recumbent  posture  with  the  head  low  and  stimulants 
administered.  Hot  applications  are  of  great  value.  If  the 
patient  is  able  to  swallow,  brandy,  5ss  to  i  (15  to  30  c.c), 
with   deodorized   tincture  of  opium,   rr^xv  to  xxx  (i  to  2  c.c). 


200  DISEASES    OF    THE    MOUTH. 

should  be  given  at  once  and  repeated  if  the  occasion  requires  it. 
Aromatic  spirit  of  ammonia,  f  5i  (4  c.c),  in  hot  water  or  milk 
every  half  hour  is  a  useful  adjunct.  If  the  patient  is  unable 
to  swallow,  these  remedies  may  be  given  by  enema,  or  whiskey, 
strychnin  sulphate,  and  tincture  of  digitalis  may  be  used  hypo- 
dermically.  As  convalescence  begins,  tonic  doses  of  quinin 
hydrochlorid  and  strychnin  sulphate  should  be  prescribed. 

In  sunstroke,  the  indications  for  treatment  are  directly  oppo- 
site. The  patient  is  in  imminent  danger  from  the  extraordin- 
ary temperature,  and  measures  to  reduce  it  must  at  once  be 
instituted.  Of  these  none  give  such  excellent  results  as  rub- 
bing with  ice,  the  cold  bath  or  cold  pack,  and  cold  effusions,  cold 
enemata,  and  the  hypiodermic  use  of  quinin  sulphate  or  anti- 
pyrin.  The  tendency  to  subsequent  rise  of  temperature  is 
met  by  wrapping  the  patient  in  a  wet  sheet  and  repeating  the 
hypodermic  medication,  unless  consciousness  has  been  regained, 
when  the  remedies  may  be  given  by  the  mouth.  If  convulsions 
and  restlessness  occur,  morphin  sulphate,  gr,  1/4  to  1/2  (0.016 
to  0.032  gm.),  hypodermically,  cautiously  repeated  if  necessary, 
or  chloral  or  bromids  by  the  rectum  will  be  of  value.  In  the 
occurrence  of  depression,  strychnin  sulphate,  gr.  1/24  (0.0025) 
gm.),  repeated  every  half  hour  hypodermically,  together  with 
other  modes  of  stimulation,  is  indicated.  Hypodermoclysis 
and  enteroclysis  may  also  be  of  value  under  such  circumstances. 
During  convalesence  iron,  quinin,  and  other  tonics  are  required. 

DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

DISEASES  OF  THE  MOUTH. 

Introduction. — The  angles  of  the  mouth  may  be  seats  of 
radiating  scars  due  to  old  syphilitic  cracks  or  fissures.  Herpes 
or  fever  blisters  in  the  same  situation  may  lead  to  more  or  less 
confusion,  but  the  duration  and  absence  of  scarring  will  soon 
render  the  diagnosis  clear.  The  inside  of  the  lips,  the  buccal 
mucous  membrane,  and  the  tonsils  may  be  affected  by  the 
initial   lesion   of   syphilis,    the   chancre,    and   in   all   indurated 


CATARRHAL   STOMATITIS.  20I 

lesions  in  these  situations  this  disease  should  be  carefully  con- 
sidered. Mucous  patches  or  moist  papules  are  common  on  the 
mucous  membrane  of  the  mouth  and  their  importance  arises 
from  their  contagious  nature.  Inflammation  of  the  gums,  or 
gingivitis,  is  a  rare  condition  which  may  arise  from  gonorrheal 
infection,  mercurial  poisoning,  scurvy,  and  other  similar  con- 
stitutional diseases.  A  blue  line  on  the  gums,  near  the  inser- 
tion of  the  teeth,  is  indicative  of  lead-poisoning.  First  denti- 
tion is  usually  completed  at  the  end  of  the  second  year,  and  the 
permanent  teeth  begin  to  appear  in  the  sixth  year,  any  delay 
in  dentition  or  the  eruption  of  badly  formed  teeth  is  attributed 
to  nutritional  disorders,  such  as  occur  in  rickets  and  syphilis. 
Hutchinson  s  teeth  consist  in  certain  characteristic  alterations 
in  the  permanent  teeth,  and  indicate  congenital  syphilis.  The 
lateral  incisors  are  peg-shaped,  and  the  central  incisors  have 
convex  sides  and  notched  cutting  edges.  Carious  teeth  may 
arise  from  uncleanliness  of  the  mouth,  drugs,  and  nutritional 
.  disturbances. 

As  a  mouth- wash  for  soft  and  spongy  gums,  the  following 
is  recommended  by  Whitla: 

I^.     Tincturae  myrrhas  ] 

Tincture  krameriae 

Tincturae  cinchonoe 

Tinctiirae  catechu  J 

Eau  de  Cologne,  oj-  32  c.c. 

M.  S. — A  teaspoonful  in  a  wineglassful  of  water,  to  be  used 
as  a  mouth- wash. 

CATARRHAL  STOMATITIS. 

Synonyms. — Simple     stomatitis;     erythematous     stomatitis. 

Description. — An  acute  catarrhal  inflammation  of  the  whole  or 
a  portion  of  the  mucous  membrane  of  the  mouth  and  tongue, 
characterized  by  pain,  redness,  swelling,  restlessness,  slight 
fever,  fetor  of  the  breath,  and  disordered  secretion.  It  is 
most  common  in  infants  and  children.  It  results  from  the 
introduction    of    irritants'  into    the    mouth,     gastrointestinal 


aa  oiv  16  c.c. 

I 


202  APHTHOUS    STOMATITIS. 

disturbances,  delayed  dentition,  and  the  infectious  fevers. 
Chronic  stomatitis  occurs  mostly  in  adults  as  the  result  of 
alcoholic  or  tobacco  excesses,  or  of  carious  or  of  baldy  arranged 
artificial  teeth. 

Treatment. — The  most  important  point  in  the  treatment  is 
the  removal  of  the  exciting  cause,  attention  to  the  secretions 
and  diet,  and  gently  mopping  out  the  mouth  at  frequent  in- 
tervals with  a  soft  wad  of  absorbent  cotton  and  cold  or  iced 
water,  or  diluted  Dobell's  solution  (see  page  64),  or  the  follow- 
ing: 

]^.      Sodii  boratis g^-xc  6.  gm. 

Aquae  destillat f  §iss  45  .  c.c. 

Mel.  rosae f  oiss  45  .  c.c. 

M.  S. — Mouth-wash. 

In  severe  or  aggravated  cases  a  dilute  solution  of  silver 
nitrate,  gr.  ij  to  v  (0.13  to  0.32  gm.),  to  f5j  (30  c.c),  should 
be  applied. 

APHTHOUS  STOMATITIS. 

Synonyms. — Follicular  stomatitis;  vesicular  stomatitis;  her- 
petic stomatitis;  croupous  stomatitis;  canker.  Note. — Aph- 
thous stomatitis  is  not  aphthae;  the  latter  is  synonymous 
with  thrush  (see  page  204). 

Description. — An  acute  inflammation  of  the  follicles  and 
mucous  membrane  of  the  mouth  and  tongue,  characterized  by 
a  fibrinous  or  croupous  exudation;  the  exudation  first  appear- 
ing in  isolated  spots  {discrete),  afterward  coalescing,  and  form- 
ing large  and  irregular-sized  patches  {confluent)  which  rupture, 
leaving  an  ulcer,  which  slowly  heals.  The  disease  occurs 
mostly  in  childhood  and  is  due  to  diffcult  dentition,  disorders 
of  digestion,  uncleanliness,  and  the  eruptive  fevers.  The 
lesions  appear  usually  as  small  white  vesicles  which  subse- 
quently rupture.  Pain,  difficulty  in  swallowing,  salivation, 
feverishness,  and  fetor  of  the  breath  are  present. 

Treatment. — The  exciting  cause  should  be  removed  if  pos- 


ULCERATIVE    STOMATITIS.  203 

sible.  The  mouth  should  be  cleansed  after  each  feeding,  and 
nursing  bottles  and  nipples  should  be  sterilized  by  boiling. 
Digestive  disturbances  should  be  corrected  by  the  administra- 
tion of  powders  containing  calomel,  gr.  I/12  (0.005  gm.). 
and  sodium  bicarbonate,  gr.  i  (0.065  g^n.)  every  three  hours. 
Small  doses  of  quinin  sulphate  may  be  necessary  in  protracted 
cases.  Locally,  chlorate  of  potassium  or  boric  acid  in  solution 
will  be  of  benefit.  The  ulcers  may  be  touched  with  a  weak 
solution  of  silver  nitrate  (gr.  iv  to  f  5i).  Honey  and  borax — 
the  mel  boracis  of  the   British  Pharmacopoeia  is  also  efficacious. 

ULCERATIVE  STOMATITIS. 

Synonyms. — Pseudomembranous  stomatitis;  fetid  stomati- 
tis; putrid  sore  mouth. 

Definition. — An  acute  and  severe  inflammation  of  the 
mucous  membrane  of  the  mouth  attended  with  necrosis  and 
■terminating  in  ulceration. 

Causes. — It  is  probably  infectious  in  character  but  no  specific 
microorganism  is  yet  recognized  as  the  cause.  It  may  be 
epidemic,  and  is  apt  to  accompany  or  follow  improper  feeding, 
infectious  diseases,  or  metallic  poisoning.  L^nhygienic  sur- 
roundings and  local  irritation  are  also  factors. 

Symptoms. — It  begins  with  swelling  of  the  mucous  membrane 
about  the  base  of  the  teeth  and  adherent  deposits  appear  on 
the  gums,  which  eventually  become  gray  or  black  and  separate 
as  sloughs,  leaving  behind  irregular  ulcers.  The  lower  jaw  is 
most  often  affected,  but  it  may  extend  to  the  lips,  cheeks,  or 
tongue.  The  submaxillary  glands  are  swollen  and  tender. 
Pain  is  present;  mastication  and  deglutition  are  difficult;  the 
mouth  is  hot;  the  saliva  dribbles  away  mixed  with  blood  and 
pulpy  matter;  the  breath  is  fetid;  anorexia  is  present;  the 
patient  is  feverish  and  restless;  and  the  gastrointestinal  tract 
is   disordered   in   its   functions. 

Prognosis. — A  favorable  termination  may  be  expected  when 
the  affection  is  promptly  and  properly  treated  and  when  the 
ulcerated  surface  is  not  too  extensive. 


204  THRUSH. 

Treatment. — The  exciting  and  contributory  causes  should 
be  immediately  removed.  Internally  potassium  chlorate,  gr. 
I  to  5  (0.065  "to  0-32  gni.),  should  be  administered  in  solution 
every  three  hours.  Iron,  quinin,  strychnin,  and  alcohol  may 
be  necessary  if  there  is  much  depression.  Locally,  potassium 
chlorate  solution,  bismuth,  alum,  or  silver  nitrate  solution, 
may  be  applied.  Potassium  permanganate  (in  the  form  of 
Condy's  fluid,  one  teaspoonful  to  a  tumbler  of  water)  is  a  use- 
ful wash.  If  the  mouth  is  particularly  sensitive  and  tender 
a  little  opium  may  be  added  to  the  mouth-washes  that  are 
used. 

THRUSH. 

Synonyms. — Parasitic  stomatitis;  mycotic  stomatitis;  muguet ; 
soor;  stomatomycosis;  aphthse.  {Note. — This  is  not  aphthous 
stomatitis,  see  page  202.) 

Description. — An  inflammation  of  the  mucous  membrane  of 
the  mouth,  associated  with  or  caused  by  the  growth  of  a  para- 
sitic plant,  the  Oidium  albicans;  characterized  by  pain,  disorders 
of  digestion  and  of  the  bowels.  It  is  most  common  in  bottle-fed 
infants,  but  may  be  seen  in  adults  in  the  last  stages  of  cancer 
or  consumption.  The  mucous  membrane  of  the  mouth  presents 
a  dark  red  appearance  in  isolated  patches  on  which  whitish 
points  appear  and  rapidly  coalesce.  These  whitish  points  are 
made  up  of  epithelium,  fat,  and  fungus,  and  resemble  curdled 
milk.  The  symptoms  common  to  the  other  forms  of  stomatitis 
are  also  present. 

Prognosis. — The  termination  is  favorable  under  treatment 
in  all  cases  except  those  due  to  malignant  diseases. 

Treatment. — Absolute  cleanliness  as  regards  the  baby's 
mouth,  nursing  bottles,  nipples,  etc.,  is  necessary.  The  dis- 
ordered digestive  tract  should  receive  attention,  largely  by 
the  proper  modification  of  the  milk.  A  saturated  solution  of 
sodium  hyposulphite,  niiii  to  x  (0.18  to  0.6  c.c),  may  be  given 
internally  and  also  applied  locally.  Sodium  bicarbonate,  and 
sodium  biborate  may  also  be  employed  locally. 


GANGRENOUS   STOMATITIS.  205 

I}.      Sodii  boratis r.  Ix      g  4.  gm. 

Glycerini f  3  ij  8  .  c.c. 

Aquae f  5  vj  24  .  c.c. 

M.  S. — To  be  thoroughly  applied  four  or  five  times  daily, 
and  continued  for  a  week  after  the  disappearance  of  the 
affection. 

Honey  is  to  be  avoided,  since  it  may  induce  acid  fermentation; 
hence  the  mel  boracis  referred  to  on  page  203  must  not  be  given 
in  this  condition.  In  obstinate  cases  the  patches  should  be 
wiped  and  then  touched  with  i  or  2  per  cent,  solution  of  nitrate 
of  silver. 

GANGRENOUS  STOMATITIS. 

Synonyms. — Cancnim  oris;  noma;  water-cancer. 

Definition. — An  acute,  rapidly  progressive  gangrenous  ulcera- 
tion of  the  mouth,  leading  to  extensive  sloughing  and  destruc- 
tion of  the  affected  tissues. 

Causes. — It  is  probable  that  gangrenous  stomatitis  is  due  to 
some  parasitic  microorganism,  but  its  character  is  as  yet  un- 
known. It  attacks  feeble  and  sickly  children  by  preference; 
and  is  occasionally  observed  in  adults.  It  may  occur  as  a 
primary  affection,  but  is  most  often  encountered  as  a  sequel 
to  measles,  scarlet  fever,  typhoid  fever,  or  pneumonia. 

Symptoms. — All  the  symptoms  common  to  the  other  varieties 
of  stomatitis  are  present  to  a  marked  degree.  One  of  the  first 
manifestations  is  the  penetrating,  gangrenous  odor.  The 
cheek  is  swollen  and  edematous,  and  the  skin  has  a  glazed, 
waxy  appearance.  On  eversion  of  the  cheek  a  foul  sloughing 
ulcer  is  brought  into  view,  which  shortly  perforates  the  skin 
and  discharges  externally.  Constitutional  reaction  is  severe; 
the  temperature  is  high  and  irregular;  the  pulse  rapid  and 
feeble;  and  prostration  is  marked.  Diarrhea  is  common. 
Death  usually  terminates  the  affection  in  a  week  to  ten  days. 
Recovery  is  very  rare.  Characteristics  of  the  disease  are: 
(i)  That  it  begins  on  the  inside  of  the  cheek;  (2)  that  it  is 
almost  always  unilateral;  (3)  that  it  perforates  the  whole 
thickness  of  the  cheek;  and  (4)  that  it  is  rapidly  fatal. 


206  MERCURIAL    STOMATITIS. 

Treatment  to  be  of  any  use  must  be  prompt  and  vigorous. 
E version  of  the  cheek  with  cauterization  of  the  ulcer  by  stick 
silver  nitrate,  fuming  nitric  acid,  or  the  Paquelin  cautery  is  the 
first  indication.  The  mouth  should  then  be  kept  as  clean  as 
possible  by  means  of  peroxid  of  hydrogen,  boric  acid  solution, 
or  other  mild  antiseptics.  The  strength  of  the  patient  should 
be  maintained  by  the  frequent  administration  of  nourishing 
food,  whiskey  or  brandy,  quinin,  iron,  strychnin,  and  other 
tonics. 

MERCURIAL   STOMATITIS. 

Synonym. — Mercurial  ptyalism. 

Etiology  and  Symptoms. — The  ingestion  and  absorption  of 
mercurial  preparations  in  excess  of  their  physiologic  dose  or  in 
abnormally  susceptible  individuals  induce  tenderness  of  the 
gums,  fetor  of  the  breath,  metallic  taste,  increase  in  saliva, 
and  redness  of  the  mucous  membrane  of  the  mouth.  In  marked 
cases  salivation  is  profuse,  the  tongue  is  swollen  and  protrudes 
from  the  mouth;  and  necrosis  of  the  teeth  and  jaw  may  occur. 

Treatment. — The  mercurial  preparations  should  be  immedi- 
ately suspended,  and  potassium  iodid  administered  in  small  doses. 
A  saturated  solution  of  potassium  chlorate  should  be  employed 
as  a  mouth-wash.  Atropin  may  be  given  to  control  the  excess- 
ive secretion  of  saliva.  Tonics  are  often  necessary  to  combat 
the  anemia. 

LUDWIG^S  ANGINA. 

Synonyms. — Angina  Ludovici;  cellulitis  of  the  neck. 

Definition  and  Symptoms. — A  phlegmonous  inflammation  of 
the  floor  of  the  mouth  and  tissues  about  the  side  of  the  neck. 
It  is  probably  a  streptococcus  infection  and  is  observed  after 
the  infectious  fevers,  traumatism,  and  dental  caries.  It  may 
end  in  suppuration,  gangrene,  septicemia,  and  very  rarely 
resolution.  Pain,  swelling,  dysphagia,  dyspnea,  and  grave 
constitutional  symptoms  are  present, 


DISEASES    OF    THE    TONGUE.  207 

Treatment. — Tonics  and  stimulants  internally  and  ice  and 
leeching  locally  are  indicated.  Surgical  interference  is  usually 
necessary;  in  the  meantime  antiseptic  measures  should  be 
employed. 

DISEASES  OF  THE  TONGUE. 

Coating  of  the  Tongue. — Normally,  the  color  of  the  anterior 
two-thirds  of  the  tongue  is  a  pale  red,  while  the  posterior  third  is 
grayish.  On  the  anterior  portion  are  seen  the  fungiform 
papillae  as  bright  red  points,  and  on  the  posterior  portion  the 
circum vallate  papillae  arranged  in  two  rows  of  red  circles.  Fur 
on  the  tongue  is  due  to  accumulated  epithelium,  fungi,  and  food 
particles.  It  is  uniform  in  febrile  diseases,  gastrointestinal 
disorders,  nasopharyngeal  affections,  and  not  uncommonly 
in  health.  A  circumscribed  furring  usually  points  to  some 
local  oral  trouble.  Unilateral  furring  results  from  some  dis- 
turbance of  the  second  and  third  branches  of  the  fifth  nerve. 
Localized  thickenings  of  the  epithelium  of  the  tongue  give  to  it 
a  chart-like  appearance  to  which  the  term  geographic  tongue  is 
applied.  Intense  white  spots  on  the  mucous  membrane  con- 
stitute leukoplakia.  The  pale  tongtie  is  noticed  in  anemia. 
The  dry,  brown,  and  fissured  tongue  accompanies  the  low  fevers, 
such  as  typhoid  fever  and  dysentery.  The  black  tongue  may 
be  parasitic  in  nature,  but  is  usually  observed  in  malignant 
fevers.  A  bhiish-black  tongtie  is  occasionally  seen  in  Addison's 
disease.  The  red,  beefy  tongue  is  most  often  encountered  in 
diabetes  and  similar  wasting  diseases.  The  strawberry  tongue 
consists  of  a  more  or  less  uniform  whitish  coating,  through 
which  project  the  bright  red  fungiform  papillae;  it  is  seen  in 
scarlet  fever.  Trembling  tongue  may  be  seen  in  paresis  and 
similar,  nervous  diseases,  alcoholism,  and  asthenic  fevers. 

GLOSSITIS. 

Definition. — An  inflammation  of  the  parenchyma  of  the 
tongue;  characterized  by  great  swelling  of  the  organ,  with  diffi- 
cult mastication,  deglutition,  and  vocalization.    It  may  be  acute 


208  SYPHILIS    OF    THE    TONGUE. 

or  chronic.  The  affection  may  be  due  to  injury,  contact  with 
boiling  liquids  or  other  irritating  substances,  or  stings  of  insects. 

Symptoms. — The  tongue  is  swollen,  painful,  and  sometimes 
protrudes  from  the  mouth,  thus  interfering  with  mastication 
and  deglutition.  The  discomfort  is  extreme.  The  voice  is 
muffled  and  there  may  be  dyspnea.  There  is  increased  flow  of 
saliva.  Fever  and  other  constitutional  phenomena  are  present. 
Suppuration  may  occur.  Acute  glossitis  usually  terminates 
in  recovery  within  a  week,  although  death  may  occur  from  suffo- 
cation. Chronic  glossitis  persists  indefinitely,  being  manifested 
largely  by  pain  aggravated  by  movements  of  the  tongue. 

Treatment. — The  application  of  ice  to  the  tongue  and  to  the 
jaw  affords  relief  in  most  cases.  Occasionally  heat  must  be  sub- 
stituted. Deep  scarification  is  necessary  in  aggravated  cases. 
Suppuration  indicates  prompt  incision.  Antiseptic  mouth 
washes  should  be  employed  constantly.  In  chronic  glossitis, 
silver  nitrate  in  stick  or  solution  should  be  applied  to  ulcerated 
areas.  The  constitutional  phenomena  should  be  treated  on 
general  principles.  If  suffocation  appears  imminent  tracheot- 
omy must  be  performed. 

SYPHILIS  OF  THE  TONGUE. 

Syphilis  of  the  tongue  may  appear  as  the  chancre,  mucous 
patch,  or  gumma.  The  characteristics  of  these  lesions  are 
maintained  in  this'  structure.  The  chancre  is  distinguished 
largely  by  its  parchment-like  induration,  and  the  age  at  which 
it  appears.  The  mucous  patch  is  usually  associated  with  other 
signs  of  secondary  syphilis  and  the  gumma  is  diagnosed  by 
exclusion  and  the  therapeutic  test. 

Treatment. — Mercury  and  the  iodids,  alone  or  combined, 
should  be  administered  over  an  extended  period. 

ULCERATION  OF  THE  TONGUE. 

Simple  ulceration  may  result  from  carious  teeth,  gastro- 
intestinal irritation,   and  contact  with  irritants.     The  under- 


LEUKOPLAKIA    BUCCALIS.  209 

lying  causes  should  be  removed  and  the  ulcerated  areas  touched 
with  silver  nitrate  in  stick  form  or  in  solution. 

Tuberculous  ulceration  is  rare  and  appears  on  the  dorsum,  near 
the  tip  of  the  tongue,  as  an  irregularly  oval  ulcer  with  under- 
mined edges  and  an  uneven  base,  which  is  covered  with  coarse 
pinkish-gray  granulations.  It  is  incurable.  The  general 
treatment  for  tuberculosis  may  be  employed,  supplemented  by 
the  use  of  the  iic-ray. 

Malignant  ulceration  is  usually  due  to  epithelioma,  and  occurs 
with  greatest  frequency  in  men  past  forty  years  of  age.  The 
lesion  has  hard  and  everted  edges,  with  an  uneven,  excavated 
base.  The  adjacent  tissues  are  infiltrated  and  indurated,  and 
the  neighboring  glands  are  involved.  Neuralgic  pain  is  con- 
stant. Removal  of  the  organ  is  indicated.  The  affection 
terminates  fatally.      Radiotherapy  may  be  of  benefit. 

LEUKOPLAKIA  BUCCALIS. 

Synonyms. — Smoker's  tongue;  smoker's  patches;  ichythosis 
lingualis. 

Description. — It  is  of  unknown  origin,  but  is  most  common 
in  smokers;  it  consists  of  irregular,  smooth,  white  patches  on 
the  tongue,  and  sometimes  on  the  inside  of  the  cheek. 

Treatment. — It  is  very  obstinate  to  treatraent.  All  irritants 
should  be  avoided.  Silver  nitrate  (10  per  cent,  solution), 
chromic  acid  (i  per  cent,  solution),  and  corrosive  sublimate 
(i:  500)  have  been  recommended  for  local  use;  but  too  active 
treatment  should  be  avoided. 

FOUL  BREATH. 

The  chief  causes  of  this  condition  are:  pyorrhea  alveolaris; 
tonsillitis;  diphtheria;  indigestion;  diseases  of  mouth,  pharynx, 
or  stomach;  decayed  teeth,  and  neglect  of  proper  hygiene  of 
mouth  and  teeth;  diseases  of  nose,  bronchi  or  lungs;  chronic 
constipation;  mineral  poisons. 

The  treatment  consists  in  discovering  and,  if  possible,  removing 
the  cause.  The  teeth  and  gums  should  receive  the  first  atten- 
14 


2IO  ACUTE    CATARRHAL    PHARYNGITIS. 

tion;  the  former  should  be  cleansed,  and  the  latter  sponged 
with  a  solution  of  myrrh  and  water.  A  mouth-wash  of  thymol 
gr.  vijss  (0.50  gm.),  borax  gr.  xv  (i.o  gm.),  and  distilled 
water  i  pint  (500  gm.)  may  be  used;  or  i  grain  of  potassium 
permanganate  to  i  ounce  of  rose  water.  The  following,  to  be 
used  as  wafers,  have  also  been  recommended: 

I^.      Pulv.  carui  sem., 

Pulv.  coriandri  sem., 

Pulv.  cinnam aa    5ss  2  .  gm. 

Sach.  alb 5i  4 .  gm. 

Mucil.  gum.  acaciae q.  s. 

S. — Make   fifty   pills.      Dissolve   one   in    the    mouth    when 
necessary. 

I^.     Pulv.  cinnam., 

Pulv.  pimentae, 

Pulv.  cardam aa    5ss  2  .  gm. 

Sacchari  alb oi  4.  gni. 

Mucil.  gum.  acaciae q.  s. 

S. — Make   fifty   pills.      Dissolve    one   in   the   mouth   when 
necessary. 

DISEASES  OF  THE  PHARYNX  AND  TONSILS. 
ACUTE  CATARRHAL  PHARYNGITIS. 

Synonyms. — Sore  throat;  simple  angina. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  tonsils,  uvula,  soft  palate,  and  pharynx ;  charac- 
terized by  rigors,  fever,  painful  deglutition,  coughing,  or  con- 
stant desire  to  clear  the  throat,  with  a  more  or  less  decided 
nasal  intonation  of  the  voice. 

Causes. — Exposure  to  cold  and  wet,  infective  microorgan- 
isms, local  irritants,  such  as  hot  liquids  and  noxious  gases, 
rheumatism,  gout,  and  the  eruptive  fevers  may  give  rise  to 
acute  pharyngitis. 

Symptoms. — The  onset  is  sudden,  usually  with  rigors  followed 
by  fever,  thirst,  headache,  anorexia,  coated  tongue,  foul 
breath,  dryness  of  the  throat,  painful  deglutition,  hoarseness. 


CHRONIC    PHARYNGITIS.  211 

and  a  constant  desire  to  clear  the  throat,  due  to  the  increased 
length  of  the  uvula.  Extension  to  the  Eustachian  tube  and 
middle  ear  gives  rise  to  deafness  and  earache.  The  nasal  tone 
of  the  voice  is  almost  pathognomonic.  Inspection  of  the  phar- 
ynx reveals  an  intensely  red  and  swollen  condition  of  the 
mucous  membrane.  The  tonsils  and  larynx  may  also  be  in- 
volved. Secretions  are  first  lessened,  but  soon  become  increased 
and  assume  a  thick,  tenacious,  opaque  character. 

Prognosis. — Favorable.  The  affection  terminates  in  three  or 
four  days  by  the  discharge  of  a  quantity  of  thick,  opaque  mucus. 

Treatment. — "  Twenty-four  hours,  rest  in  bed  is  by  far  the 
best  medicine  for  an  ordinary  cold"  (Tyson).  Cases  resulting 
from  exposure  are  benefited  by  the  application  of  bicarbonate 
of  sodium  by  insufflation.  Opium  alone  or  combined  with 
ipecac  or  camphor  will  often  abort  an  attack.  Pain  may  be 
relieved  by  the  administration  of  salol.  gr.  iii  (0.2  gm.),  phen- 
acetin,  gr.  iii  (0.2  gm.),  and  powdered  camphor,  gr.  i  (0.65 
•gm.),  four  to  six  times  daily.  Tincture  of  the  chlorid  of  iron 
in  doses  of  2  to  10  minims  may  be  given.  Sodium  salicylate, 
gr.  X  to  XV  (0.6  to  I  gm.)  every  hour,  for  six  hours,  is  of 
great  benefit.  Tincture  of  aconite  or  potassium  citirate,  may 
be  given  to  control  the  fever.  The  bowels  should  always  be 
freely  opened  early  in  the  treatment. 

Locally  the  application  of  a  4  per  cent,  solution  of  cocain 
or  cocain  lozenges  will  afford  considerable  relief.  Ice  pellets 
in  the  mouth  and  heat  or  cold  applied  externally  also  produce 
benefit.  Gargles  or  sprays  of  alum  (gr.  viii  to  f  oi),  ammonium 
chlorid  (gr.  xx  to  f  §i),  or  potassium  chlorate  (gr.  x  to  f  §i), 
often  relieve  the  swelling  and  congestion. 

The  severe  cases  are  nearly  always  secondary  affections, 
and  their  treatment  is  that  of  the  primary  diseases. 

CHRONIC  PHARYNGITIS. 

Synonyms. — Clergyman's  sore  throat;  granular  pharyngitis; 
chronic  angina. 

Description. — Chronic  inflammation  of  the  pharynx  follows 
repeated   acute    attacks,    prolonged    irritation,    long-continued 


212  ULCERATION  OF  THE  PHARYNX. 

overuse  and  improper  use  of  the  voice,  chronic  rhinitis,  and  di- 
gestive disturbances.  It  is  common  in  hucksters,  pubhc  speak- 
ers, singers,  and  smokers.  It  is  more  common  in  adults  than 
in  children ;  and  the  inhalation  of  dust  and  irritating  gases  may 
also  induce  the  trouble.  In  the  early  stage  the  mucous  mem- 
brane is  in  a  state  of  chronic  hyperemia;  and  is  thick,  swollen, 
and  studded  with  distended  follicles  and  enlarged  lymphatic 
glandules  which  give  to  it  a  granular  appearance.  In  the  later 
stage  the  mucous  membrane  undergoes  atrophic  changes,  and 
is  anemic  glossy,  and  dry.  As  a  result  of  these  changes  the  voice 
is  husky,  and  the  throat  is  dry.  Distress  follows  the  use  of  the 
voice  and  there  is  a  constant  desire  to  clear  the  throat. 

Treatment. — As  a  prophylactic,  in  "threatened"  sore  throat, 
the  following  has  been  recommended: 

I^.     Acidi  tannici gr.  xij  o  •  75  giri. 

Tincturas  iodi ttlv  0.32  c.c. 

Acidi  carbolici gr.  xxx  2 .       gm. 

Glycerini 5ss  16.       c.c. 

Aquae q.  s.  ad    5iij  96.       c.c. 

M.  S. — Paint  the  throat  with  this  three  times  a-  day. 

The  underlying  causes  should  be  promptly  removed.  Tonics 
such  as  iron,  quinin,  strychnin,  and  cod-liver  oil,  together 
with  plenty  of  fresh  air,  should  be  prescribed.  Locally,  Dobell's 
solution  and  similar  antiseptic  solutions  should  be  used,  in  the 
pharynx  and  nose.  When  the  granules  are  present,  astringent 
applications,  such  as  zinc  sulphate  (gr.  v  to  f  Si)  and  silver 
nitrate  (gr,  x  to  xx  to  f  Bi),  or  the  galvanocautery  may  be  em- 
ployed. A  spray,  consisting  of  menthol  (gr.  ii),  eucalyptol 
(gr.  i),  and  liquid  vaselin  will  be  productive  of  great  relief. 
The  condition  may  prove  very  resistant  to  treatment. 

ULCERATION  OF  THE  PHARYNX. 

Ulceration  of  the  pharynx  seldom  follows  simple  chronic 
pharyngitis,  but  results  from  syphilis,  tuberculosis,  diphtheria, 
typhoid  fever,  or  scarlet  fever.  The  history,  character  of  the 
ulceration,  and  reaction  to  treatment  will  aid  greatly  in  making 


ACUTE    TONSILLITIS.  213 

a  diagnosis.  The  syphilitic  ulcer  is  either  painless,  or  but 
slightly  painful,  and  is  generally  on  the  posterior  wall  of  the 
pharynx.  The  tubercular  ulcer  is  very  jjainful,  and  is  associated 
with  tuberculosis  elsewhere;  it  is  also  on  the  posterior  wall  of 
the  pharynx.  The  treatment  is  largely  that  of  the  primary 
disease,  but  locally,  in  all,  mild  antiseptic  and  stimulating 
applications  should  be  made  to  the  ulcerated  areas. 

ACUTE  TONSILLITIS. 

Synonyms. — Quinsy;  amygdalitis;  phlegmonous  pharyngitis; 
tonsillar   abscess. 

Definition. — An  acute  parenchymatous  inflammation  of  one 
or  both  tonsils,  with  a  strong  tendency  toward  suppuration. 

Causes. — The  affection  is  most  common  in  youth  and  early 
adult  life,  and  is  greatly  influenced  by  rheumatic  diathesis, 
exposure  to  cold  and  wet,  inhalation  of  foul  air,  and  previous 
attacks.  It  is  probably  due  to  infection;  and  enlarged  tonsils 
are  a  predisposing  factor. 

Symptoms. — The  onset  is  more  or  less  sudden  with  rigors, 
rise  of  temperature,  102°  to  104°  F.,  later  reaching  105°  F.,  full 
frequent  pulse,  100  to  120,  headache,  thirst,  pain  and  swelling 
at  the  angle  of  the  jaw,  difficult  and  intensely  painful  degluti- 
tion, difficult  breathing,  increased  salivation,  sometimes  drib- 
bling from  the  mouth,  muffling  of  the  voice,  and  often  impaired 
hearing  and  earache.  Inspection  reveals  marked  swelling 
and  congestion  of  the  mucous  membrane  of  the  fauces  and 
pharynx.  One  or  both  tonsils  will  be  seen  to  be  enormously 
swollen  and  projecting  toward  the  median  line.  The  surface 
is  covered  with  small,  yellowish  points  which  closely  resemble 
patches  of  false  membrane,  but  close  examination  will  show 
them  to  be  distended  follicles  from  which  cheesy,  foul-smelling 
pellets  may  be  expelled. 

If  suppuration  is  imminent,  the  throat  becomes  more  painful 
and  throbbing  in  character,  the  constitutional  reaction  becomes 
more  severe,  and  fluctuation  may  be  obtained.  Breathing  is 
extremely  difficult  and  relief  is  afforded  when  rupture  occurs 


214  ACUTE    TONSILLITIS. 

either  spontaneously  or  as  the  result  of  a  sudden  effort  at 
coughing  or  vomiting. 

The  disease  lasts  from  three  to  seven  days,  terminating  in 
resolution  or  in  suppuration. 

Diagnosis. — This  is  usually  not  difficult,  but  it  may  be  im- 
possible on  a  first  examination  to  decide  between  tonsillitis 
and  diphtheria;  hence  cultures  should  be  made  in  doubtful 
cases.  In  such  doubtful  cases  it  is  always  a  good  plan  to*lose  no 
time,  but  to  inject  antitoxin  at  once,  without  waiting  for  the 
development  of  the  bacteria;  then  if  the  case  should  afterward 
prove  to  be  diphtheria,  you  have  done  the  best  thing,  and  if  it 
should  be  proved  not  to  be  diphtheria,  no  harm  has  been  done. 

Prognosis. — As  a  rule  the  disease  ends  favorably.  Suffoca- 
tion may  occasionally  occur,  especially  in  weak  children;  this 
is  more  likely  where  a  "  double  quinsy"  causes  obstruction. 

Treatment. — See  above  under  Diagnosis.  Rest  in  bed  and 
liquid  diet  are  the  first  indications.  Calomel,  gr.  v  (0.3  gm.), 
and  sodium  bicarbonate,  gr.  v  (0.3  gm.),  should  be  administered 
immediately,  followed  in  six  or  eight  hours  by  a  saline  cathartic. 
Sodium  salicylate,  gr.  x  to  xv  (0.6  to  i  gm.)  or  cinchonidin 
salicylate,  gr.  v  (0.3  gm.),  should  then  be  given  every  two  hours 
until  six  doses  have  been  taken.  The  following  is  useful  for 
adults  and  rheumatic  cases : 

I^.      Acidi  salicylici oij  8.  gm. 

Sodii  bicarbonatis 3jss  6.  gm. 

Glycerini 5j  32  .  c.c. 

Aquae  menthag  piperitse.  .    q.  s.  ad  Biv  ad  120.  c.c. 
M.  S. — One  tablespoonful  every  two  or  three  hours. 

If  the  febrile  reaction  is  very  great,  tincture  of  aconite  may  be 
employed  in  very  small  doses,  but  if  it  is  contraindicated  in- 
ternally, for  any  reason,  it  may  be  diluted  with  glycerin  and 
painted  over  the  affected  parts.  In  advanced  cases  the  follow- 
ing will  be  found  of  value: 

I^.      Tincture  ferri  chloridi  ..    foij  8.  c.c. 

Glycerini q.  s.  ad    f  §ij  ad  60.  c.c. 

M.    S. — Teaspoonful  every  two   hours,  undiluted.      Not  to 
be  followed  by  food  for  one  hour. 


HYPERTROPHY   OF    THE    TONSILS.  21 5 

Among  the  other  remedies  useful  in  this  condition  are  the 
ammoniated  tincture  of  guaiac,  sodium  benzoate,  salol,  and 
phenacetin.  Ice  pellets  in  the  mouth  will  sometimes  afford 
great  relief,  opium  may  be  necessary  at  times. 

Locally,  ice  or  heat  may  be  applied  to  the  angles  of  the  jaw. 
The  mouth  should  be  kept  as  clean  as  possible  by  means  of 
Dobell's  solution  and  peroxid  of  hydrogen.  Painting  of  the 
tonsils  with  nitrate  of  silver  solution  (gr.  xl  to  f  5i)  is  recom- 
mended. Scarification  of  the  diseased  structures  is  sometimes 
very  beneficial.  The  application  of  a  solution  of  cocain  (10  per 
cent.)  may  be  of  benefit.  The  occurrence  of  suppuration  will 
necessitate  the  employment  of  hot  applications  and  early 
incision,  preferably  at  the  upper  and  free  side  of  the  gland, 
near  the  soft  palate.  When  the  acute  symptoms  have  sub- 
sided, copper  sulphate  solution  (gr.  xx  to  f  §i),  or  Monsel's 
solution  diluted  (f  oi  to  f  oi)  should  be  applied  to  hasten  shrink- 
age of  the  glands. 

HYPERTROPHY  OF  THE  TONSILS. 

Causes. — Enlargement  of  the  tonsils  may  occur  as  the  result 
of  repeated  acute  attacks  of  inflammation,  but  may  arise  inde- 
pendently. It  is  most  common  in  children.  It  may  consist 
of  hypertrophy  of  the  glandular  structure  itself,  the  connective 
tissue,  or  both.  The  consistency  depends  on  the  quantity  of 
fibrous  tissue  present.  Catarrhal  inflammation  and  adenoid 
growths   of   the   naso-pharynx   are   common   accompaniments. 

Symptoms. — Enlarged  tonsils  are  always  predisposed  to  in- 
flammation and  may  remain  unnoticed  until  such  a  condition 
arises.  Inquiry  will  elicit  the  information  that  the  patient 
breathes  almost  constantly  with  the  mouth  open,  snores  during 
sleep,  is  subject  to  night-terrors,  has  difficulty  in  swallowing, 
and  is  mentally  dull.  The  voice  is  usually  thick  and  of  a  nasal 
quality,  hearing  is  impaired,  and  the  face  has  a  stupid  expres- 
sion. Development  may  be  interfered  with,  resulting  in  nar- 
rowing of  the  anterior  nares,  contraction  of  the  superior  dental 
arch,  elevation  of  the  hard  palate,  and  the  formation  of  the 


2l6  DISEASES    OF    THE   ESOPHAGUS. 

"chicken-breast,"  so-called,  the  round  or  barrel  chest,  and  the 
funnel  breast.  There  is  fetor  of  the  breath  and  impairment 
of  the  special  senses.  Cough  and  stuttering  are  rather  common. 
Treatment. — The  enlarged  glands  and  any  pharyngeal 
adenoids  should  be  removed  by  a  surgical  operation,  after 
which,  measures  should  be  employed  to  correct  the  faulty 
development.  Fresh  air,  exercise,  proper  diet,  tonics,  etc., 
will  be  of  great  benefit. 


DISEASES  OF  THE  ESOPHAGUS. 

ESOPHAGITIS. 

Acute  inflammation  of  the  esophagus  may  result  from  the 
swallowing  of  corrosive  liquids,  lodgment  of  foreign  bodies, 
diphtheria,  and  small-pox.  Chronic  inflammation  of  the 
esophagus  results  from  venous  obstruction,  such  as  follows 
valvular  heart-disease  and  cirrhosis  of  the  liver. 

Symptoms.— The  principal  manifestations  are  pain  beneath 
the  sternum  and  difficulty  in  swallowing.  There  is  a  copious 
mucoid  secretion  which  may  be  regurgitated  or  passed  into  the 
stomach.  After  destructive  inflammation  the  resulting  cicatri- 
cial changes  may  eventually  lead  to  obstruction. 

Treatment. — Nothing  can  be  done  to  aid  in  the  cure  of  the 
local  condition.  Demulcents,  ice,  and  liquid  diet  may  be  em- 
ployed, but  if  deglutition  is  painful,  it  is  best  to  resort  to  rectal 
feeding. 

ESOPHAGEAL  OBSTRUCTION. 

Functional  obstruction  of  the  esophagus  or  esophagismus 
is  an  hysterical  condition  which  is  most  frequently  observed  in 
women  past  middle  life.  It  may  occur  also  in  chorea,  epilepsy, 
and  hydrophobia.  Male  hypochondriacs  are  sometimes  affected. 
The  condition  is  manifested  by  difficulty  in  swallowing  (which 
is  spasmodic  in  character),  choking,  and  regurgitation  of  food. 
It  may  be  excited  by  liquid  as  well  as  solid  food.     It  is  dis- 


CANCER   OF    THE    ESOPHAGUS.  21 7 

tinguished  from  other  conditions  of  the  esophagus  by  the 
paroxysmal  character  of  the  obstruction,  the  absence  of  emacia- 
tion, the  history,  age,  and  sex  of  the  patient,  and  the  ease  with 
which  a  bougie  is  passed. 

Treatment. — The  systematic  passage  of  the  esophageal  bougie 
combined  with  appropriate  measures  for  the  relief  of  the  under- 
lying neurotic  condition  generally  results  in  cure.  Care  must 
be  taken  not  to  produce  ulceration  by  the  too-frequent  employ- 
ment of  instruments. 

Organic  obstruction  of  the  esophagus  may  be  due  to  the  pres- 
ence of  a  foreign  body  in  the  lumen  of  the  tube,  a  contracting 
cicatrix  such  as  follows  ulceration,  corrosives,  acute  esophagitis, 
tumors  of  the  esophageal  wall,  such  as  cancer  and  rarely  polyps, 
and  external  tumors,  including  aneurysm,  enlarged  lymphatic 
glands,  and  mediastinal  growths.  It  is  manifested  by  slowly 
increasing  dysphagia,  which  is  in  turn  followed  either  by  regur- 
gitation of  the  food  or  dilatation  of  the  esophagus  above  the 
point  of  obstruction.  Pain  and  emaciation  are  constant,  and 
it  is  impossible  to  pass  a  bougie.  A  discharge  of  blood  and 
mucus  is  common,  after  such  attempts  in  cancerous  obstruction. 
Death  is  nearly  always  the  termination  from  starvation  or 
exhaustion. 

Treatment. — Rectal  alimentation  will  be  necessary  to  support 
the  patient  and  opium  may  be  required  to  relieve  pain.  In 
cicatricial  obstruction  bougies  may  be  employed,  but  in  other 
forms  surgical  treatment  will  be  required.  The  outlook  is 
unfavorable  except  in  cicatricial  obstruction. 

CANCER  OF  THE  ESOPHAGUS. 

Description. — It  is  usually  primary,  and  is  more  frequent  in 
males  than  in  females.  The  type  is  generally  epithelioma. 
The  tumor  most  frequently  affects  the  middle  and  lower  third 
of  the  esophagus.  The  mucous  membrane  is  first  attacked; 
this  ulcerates,  then  may  follow  stenosis,  with  hypertrophy  of 
the  wails  and  dilatation  of  the  tube  above  the  cancer.  Perfora- 
tion may  occur,  affecting  neighboring  viscera  or  vessels. 


2l8  DISEASES    OF    THE    STOMACH. 

Symptoms  and  Diagnosis. — Dysphagia,  stenosis,  regurgita- 
tion of  food,  vomiting  of  blood  and  mucus  with  fragments  of 
the  cancer,  may  all  be  present.  Pressure  symptoms  may  occur. 
Cachexia,  emaciation,  and  pain,  in  males  past  middle  life, 
accompanied  with  regurgitation  of  blood  and  food,  should 
make  the  physician  suspect  cancer. 

Prognosis. — The  disease  is  invariably  fatal.  Emaciation  is 
progressive,  and  the  patient  dies  from  asthenia  or  from  sudden 
perforation  of  the  ulcer. 

Treatment. — Treatment  is  only  palliative.  Milk  and  liquids 
may  be  swallowed,  but  sooner  or  later  rectal  feeding  is  required. 
Morphin  may  be  given  for  the  pain.  The  best  treatment  is 
undoubtedly  gastrostomy,  which  may  not  only  prolong  the 
patient's  life,  but  also  save  a  great  deal  of  suffering. 


DISEASES  OF  THE   STOMACH. 

DIAGNOSTIC  TECHNIC. 

External  Examination. — Normally,  the  greater  jgjortion  of  the 
stomach  (three-fourths)  occupies  the  upper  left  quadrant  of 
the  abdomen,  the  remaining  one-fourth  lying  to  the  right  of 
the  median  line.  The  cardiac  orifice  lies  behind  the  sternal 
attachment  of  the  sixth  or  seventh  costal  cartilages  on  the  left 
side,  while  the  pylorus  is  situated  on  the  right  side  and  above 
the  umbilicus.  In  a  moderately  distended  stomach,  the  highest 
part  of  the  fundus  is  about  the  fifth  interspace  in  the  nipple  line, 
and  the  lowest  border  is  i  to  2  inches  above  the  umbilicus  in 
men,  and  1  iji  to  3  inches  above  the  same  point  in  women. 
To  determine  these  boundaries  it  is  often  necessary  to  in- 
flate the  stomach  with  air,  after  which  the  ordinary  methods 
of  physical  diagnosis,  inspection,  palpation,  percussion,  and 
auscultation  may  be  employed.  Traube's  half-moon  space  is 
an  area  on  the  left  side  of  the  trunk,  bounded  above  by  the 
upper  edge  of  the  sixth  rib  as  far  as  the  axillary  line,  on  the 
right  side  by  liver  dullness,   on  the  left  side  by  splenic   dull- 


DIAGNOSTIC    TECHNIC.  -  219 

ness,  and  below  by  the  costal  arch.  When  the  stomach  is 
empty  and  distended  a  tympanitic  note  is  obtained  over  it  by 
percussion,  but  when  full,  it  yields  a  flat  note.  A  pleural 
effusion  on  the  left  side  may  also  render  this  area  flat 
to  percussion.  Lcichtenstern  s  pulmono-hepatic  angle  is  the 
angle  that'  -exists  at  the  junction  of  the  lower  edge  of  the  left 
lobe  of  the  liver,  and  the  lower  border  of  the  left  lung.  Its  apex 
lies  behind  the  sixth  rib,  below  the  apex  beat.  The  lung  occu- 
pies it  only  during  deep  inspiration,  and  it  is  bisected  by  the 
pleural  space.  The  angle  is  constantly  maintained  and  filled 
in  by  the  stomach.  The  outline  of  the  stomach  may  be  better 
determined  by  having  the  patient  take  in  rapid  succession  the 
two  portions  of  a  Seidlitz  powder,  and  then  proceeding  with  the 
examination. 

Internal  Examination. — To  examine  the  stomach  contents  it 
is  necessary  to  administer  a  test-meal  of  definite  quantity  and 
quality,  and  to  withdraw  it  after  a  fixed  time  has  elapsed.  The 
digestive  changes  are  then  noted  and  deductions  made  as  to  the 
state  of  function  of  the  stomach. 

Boas  and  Ewald's  test-meal  consists  of  an  ordinary  roll  weighing 
9  drams  (35  gm.),  and  10  ounces  (300  c.c.)  of  water,  or  weak  tea 
without  milk  or  sugar.  This  is  preferably  given  for  breakfast, 
when  the  stomach  is  empty.  It  is  removed  at  the  end  of  one 
hour,  and  ordinarily  from  20  to  40  c.c.  should  be  the  quantity 
withdrawn. 

Leuhe-Riegel  test-meal  consists  of  beef -soup,  13.3  ounces 
(400  gm.),  beefsteak,  6.6  (200  gm.),  bread,  1.6  (50  gm.),  and 
water  6.6  (200  c.c).  The  contents  of  the  stomach  after  this 
meal  should  be  removed  at  the  end  of  four  hours. 

In  removing  the  stomach  contents  it  is  best  to  employ  a  soft, 
flexible,  red  rubber  tube,  open  at  the  inner  end,  or  provided 
with  lateral  openings  like  a  Nelaton's  catheter,  the  length  of 
which  is  about  3  feet  (95  cm.).  The  distance  from  the  incisor 
teeth  to  the  fundus  is  about  2  feet  (60  to  65  cm.),  and  the  stom- 
ach tubes  in  common  use  are  marked  at  this  point  on  the  tube. 
To  introduce  it,  the  tube  should  be  moistened  with  water  and 
passed  well  back  into  the  pharynx,  after  which  the  patient  is 


220  DIAGNOSTIC   TECHNIC. 

directed  to  swallow,  and  the  tube  is  pushed  on  very  gently. 
In  withdrawing  the  contents  it  is  best  to  employ  siphonage,  us- 
ing a  definite  quantity  of  water  so  as  to  allow  of  its  deduction 
in  the  chemical  examination. 

Contra-indication  to  the  use  of  the  stomach-tube.  These  are 
well  summarized  by  Greene  as  follows : 

"The  following  conditions  usually  forbid  the  use  of  the  tube 
in  those  not  habituated  to  its  use:  a.  Extreme  weakness  and 
exhaustion  from  whatever  cause,  b.  Advanced  myocarditis,  c. 
Recent  hematemesis  or  tarry  stools,  d.  Advanced  arteriosclerosis 
or  post  cerebral  hemorrhage,  e.  Pregnancy,  f.  Aortic  an- 
eurysm, g.  Terminal  pulmonary  tuberculosis  especially  if 
hemoptysis  has  occurred.  h.  High  grades  of  emyhysema. 
Furthermore,  in  elderly  persons  of  apoplectic  build  and  tend- 
ency the  fi:  t  passage  of  the  tube  usually  involves  an  amount 
of  straining  and  congestion  that  is  extremely  dangerous.  These 
restrictions  need  only  apply  to  hemorrhagic  cases  and  aneurysm, 
in  those  habituated  to  the  use  of  the  tube.'' 

For  the  first  thirty  to  forty -five  minutes  of  gastric  digestion 
lactic  acid  predominates,  but  at  the  end  of  an  hour  it  is 
entirely  replaced  by  free  hydrochloric  acid,  which  exists  in 
quantities  varying  from  0.15  to  0.2  per  cent,  after  a  light  meal 
to  0.2  to  0.33  per  cent,  after  an  abundant  meal. 

To  test  for  free  acids  it  is  common  to  employ  filter  paper 
which  has  been  soaked  in  a  solution  of  Congo-red.  This  turns 
blue  in  the  presence  of  free  acids.  Tropeolin  may  be  used  in 
the  same  manner,  paper  soaked  with  it  turning  brown  under 
similar  circumstances.  These  do  not  differentiate,  however, 
between  the  mineral  acids  and  the  organic  acids. 

Reaction  of  the  stomach  contents  is  important  from  a  clinical 
standpoint,  and  should,  therefore,  always  be  obtained.  Acidity 
of  the  gastric  contents  from  0.15  to  0.2  per  cent,  is  normal,  and 
is  due  to  hydrochloric  acid;  this  condition  is  called  euchlor- 
hyhdria.  A  greater  percentage  than  this  constitutes  hyper- 
acidity or  hyperchlorhydria  and  is  common  in  neurasthenia, 
hysteria,  ulcer  of  the  stomach,  gastric  dilatation,  locomotor 
ataxia,  etc.     Sub  acidity  or  hypochlorhydria  refers  to  a  deficiency 


DIAGNOSTIC    TECHNIC.  221 

in  the  mineral  acid  although  acids  of  fermentation  may  be 
present.  It  is  encountered  in  gastric  cancer,  neurasthenia, 
hysteria,  gastric  neuroses,  anemia,  chronic  gastritis,  chronic 
diseases  of  gall-bladder,  pancreas,  etc.  Anachlorhydria  denotes 
absence  of  free  hydrochloric  acid;  it  is  found  in  gastric  cancer 
neurasthenia,  hysteria,  chronic  gastritis,  etc. 

Free  hydrochloric  acid  may  be  ascertained  by  Gunzburg's, 
Boas',  or  Toepfer's  test.  The  reagent  used  by  Giinzburg  consists 
of  phloroglucin,  30  gr.  (2  gm.),  vanillin,  15  gr.  (i  gm.),  and  ab- 
solute alcohol,  I  ounce  (30  c.c).  It  must  be  kept  in  a  dark 
bottle.  The  gastric  contents  should  be  filtered  and  a  few 
drops  of  this  solution  added  to  the  filtrate.  The  mixture  is 
evaporated  to  dryness,  a  beautiful  rose-red  tinge  at  the  edge 
indicating  free  hydrochloric  acid.  This  test  is  extremely 
delicate  and  will  detect  i  part  of  hydrochloric  f  -^"d  in  20,000 
parts  of  water.  Boas'  reagent  is  composed  of  resorcin,  75  gr. 
(5  gm.),  white  sugar,  45  gr.  (3  gm.),  and  dilute  alcohol,  31/2 
ounces  (100  c.c).  It  is  applied  in  the  same  manner  as  the 
preceding,  the  hydrochloric  acid  being  indicated  by  a  purple- 
red  color.  Toepfer's  reagent  is  a  0.5  per  cent,  alcoholic  solution 
of  dimethyl-amidoazobenzol.  One  or  2  drops  added  to  5  c.c. 
of  the  gastric  filtration  will  turn  the  mixture  a  bright  cherry- 
red  in  the  presence  of  free  hydrochloric  acid. 

Neither  Gunzburg's  nor  Boas'  test  responds  to  organic 
acids,  or  is  interfered  with  by  acid  salts  or  peptones. 

To  deter'inine  the  total  acidity  of  the  gastric  contents,  the  most 
convenient  method  is  to  add  i  drop  of  a  i  per  cent,  solution 
of  phenolphthalein  to  10  c.c.  of  the  gastric  filtrate  and  neu- 
tralize this  mixture  with  a  decinormal  solution  of  sodium 
hydrate  from,  a  Mohr's  burette.  A  red  coloration  of  the 
filtrate,  which  fails  to  disappear  on  shaking,  indicates 
complete  neutralization.  The  number  of  cubic  centimeters 
of  the  sodium  hydrate  required  is  read  from  the  scale  and  then 
multiplied,  by  ten  to  obtain  the  percentage  of  total  acidity,  for 
for  instance,  if  4  to  6  c.c.  (the  usual  quantity)  were  employed 
for  10  c.c.  of  the  filtrate,  the  percentage  of  total  acidity  would  be 
40  to  60.      The  quantity  of  free  hydrochloric  acid  may  easily  be 


222  DIAGNOSTIC    TECHNIC. 

obtained  (when  it  exists  alone)  if  it  is  remembered  that  i  c.c. 
of  the  alkaline  solution  is  equivalent  to  0.00365  gm.  of  hydro- 
chloric acid.  Giinzburg's  reagent  is  applicable  in  this  test  as 
in  the  preceding  for  qualitative  purposes.  Toepfer's  reagent 
may  also  be  employed  in  a  similar  manner  for  the  same  purpose. 
A  I  per  cent,  aqueous  solution  of  alizarin  is  sometimes  used; 
neutralization  of  the  gastric  filtrate  containing  a  few  drops  of 
it,  by  the  decinormal  sodium  hydrate  solution  is  evidenced  by 
a  violet  color.  In  all,  it  is  customary  to  employ  10  c.c.  of  the 
filtrate,  using  the  reagents  to  test  for  the  presence  of  acid 
until  it  is  completely  neutralized  by  the  alkali  solution. 

Lactic  acid  may  be  detected  by  Uffelmann's  test.  Uffel- 
fnanns  reagent  is  composed  of  a  4  per  cent,  solution  of  carbolic 
acid,  10  c.c,  distilled  water,  20  c.c,  and  the  official  neutral 
ferric  chlorid  solution,  i  drop.  The  mixture  should  be  freshly 
made  and  should  possess  an  amethyst-blue  color.  The  presence 
of  lactic  acid  will  be  indicated  by  a  canary-yellow  color  on 
mixing  the  reagent  with  the  gastric  filtrate.  This  test  will 
detect  I  part  of  lactic  acid  in  20,000  parts  solution.  The 
presence  of  lactic  acid  in  any  marked  degree  is  almost  pathog- 
nomonic of  gastric  cancer;  but  its  absence  does  not  deny  the 
existence  of  cancer.  It  may  also  be  found  in  gastric  dilata- 
tion. 

Btttyric  acid  is  distinguished  by  its  characteristic  odor  on 
boiling  the  filtrate  and  by  its  brownish  yellow  reaction  with 
Uffelmann's  solution.  It  may  also  be  separated  in  drops  by 
the  addition  of  calcium  chlorid.  When  not  due  to  ingestion  of 
fats,  butyric  acid  may  be  found  in  the  same  conditions  as 
lactic  acid. 

Acetic  acid  may  be  recognized  by  its  odor  or  by  the  dark 
^ed  color  it  produces  with  ferric  chlorid  solution.  To  obtain 
this,  it  is  first  extracted  from  the  filtrate  by  ether,  then 
evaporated,  and  the  residue  dissolved  in  distilled  water,  after 
which  it  is  neutralized  by  a  solution  of  sodium  carbonate.  Ace- 
tic acid  may  be  found  after  the  ingestion  of  alcohol,  otherwise 
it  has  the  same  significance  as  lactic  acid. 

Alcohol  resulting  from  yeast  fermentation   in   the   stomach 


DIAGNOSTIC    TECHNIC.  223 

may  be  detected  by  Liebens  iodoform  test.  The  gastric  contents 
should  be  distilled,  and  a  small  quantity  of  liquor  potassae 
added  to  the  distillate;  a  few  drops  of  a  solution  of  iodin  and 
potassium  iodid  are  then  added,  and  if  alcohol  is  present  iodo- 
form will  be  precipitated  from  the  mixture.  (Use  i  part  of  the 
distillate,  2  of  liquor  potassae,  and  50  of  the  solution  of  iodin 
and  potassium  iodid). 

Propeptone  and  peptone,  the  products  of  albumin  digestion, 
yeild  a  purplish-red  color  on  the  addition  of  Fehling's  solution. 

Rennet  or  Lab  ferment  is  detected  by  its  action  on  raw  milk. 
A  few  drops  of  the  gastric  filtrate  should  be  added  to  3.6  drams 
(10  c.c.)  of  raw  milk  and  the  mixture  placed  in  a  chamber  at  an 
average  temperature  of  100°  F.  The  presence  of  the  ferment 
is  indicated  by  coagulation  of  the  milk.  Rennet  does  not 
exist  primarily  as  such,  but  as  rennet-zymogen, which  has  no 
effect  on  milk.  It  may  be  converted  into  rennet  by  the  addi- 
tion of  hydrochloric  acid  or  calcium  chlorid.  Its  absence  may 
denote  carcinoma,  atrophic  gastritis,  or  achylia  gastrica. 

Pepsin  is  usually  present  in  the  filtrate,  in  which  hydrochloric 
acid  has  been  detected,  but  if  it  is  absent  it  should  be  supplied 
in  sufficient  quantity  and  slices  of  coagulated  white  of  egg 
added  to  the  mixture.  The  whole  is  placed  in  an  oven  at  100° 
F.,  and  in  the  presence  of  pepsin,  dissolution  of  the  eggs  should 
occur  within  an  hour. 

Starch  products  in  the  filtrate  will  be  indicated  by  the  deep 
blue  color  produced  by  contact  with  iodin  or  Lugol's  solution  of 
iodin  (i),  potassium  iodid  (2),  and  distilled  water  (200).  In 
the  absence  of  such  reaction  it  may  be  inferred  that  starch 
digestion  has  been  complete. 

Sahli's  Desmoid  Reaction.  This  is  a  test  for  gastric  digestion 
without  the  use  of  the  stomach-tube.  Methylene  blue  for 
potassium  iodid,  or  salicylic  acid)  are  used.  A  small  quantity 
is  placed  in  a  little  rubber  bag  which  is  then  securely  closed 
with  pliable  catgut.  The  patient  swallows  this  immediately 
after  a  full  meal,  being  careful  not  to  bite  it.  If  the  stomach 
functions  are  normal,  the  methylene  blue  will  impart  to  the 
urine  a  greenish  blue  color  in   about   sixteen  hours;  if  hyper- 


2  24  ACUTE    GASTRITIS. 

acidity  be  present,  the  reaction  occurs  about  five  or  six  hours 
later;  in  hypoacidity,  not  for  twenty-four  hours.  (The  time 
may  vary  according  to  the  make  of  catgut.)  The  elimination 
of  the  methylene  blue  is  delayed  in  advanced  cardiac  and  renal 
disease,  and  also  in  enteritis. 

The  rate  of  absorption  is  indicated  by  the  period  necessary  for 
free  iodin  to  appear  in  the  saliva  after  the  ingestion  of  a  capsule 
containing  o.i  gm,  of  potassium  iodid.  Normally  ten  or  fifteen 
minutes  is  sufficient.  Filter  paper,  impregnated  with  starch, 
is  used  as  the  reagent ;  and  a  blue  reaction  indicates  the  appear- 
ance of  the  iodin  in  the  saliva. 

The  motor  power  of  the  stomach  may  be  ascertained  in  several 
ways:  (i)  Withdrawal  of  the  gastric  contents  six  to  seven  hours 
after  the  ingestion  of  the  Leube-Riegel  test-meal  should  demon- 
strate no  solid  residue  if  the  motor  power  is  normal.  (2)  Sali- 
cyluric acid  should  appear  in  the  urine  within  one  hour  after  the 
ingestion  of  15  gr.  (i  gm.),  of  salol,  under  normal  conditions. 
The  acid  is  detected  by  the  violet  color  produced  on  contact 
with  a  10  per  cent,  solution  of  ferric  chlorid. 

Microscopic  examination  of  the  stomach  contents  may  reveal 
the  presence  of  starch-cells,  yeast-cells,  muscle-fibers,  shreds  of 
mucous  membrane,  epithelium,  Oppler-Boas  bacillus,  pus-cells, 
blood  corpuscles,  and  various  bacteria. 

ACUTE  GASTRITIS. 

Synonyms. — Simple  gastritis;  gastric  fever;  gastric  catarrh; 
acute  dyspepsia. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach. 

Causes. — It  may  arise  from  overloading  the  stomach,  or 
from  the  presence  in  the  stomach  of  undigested  or  indigestible 
foods,  alcoholic  beverages  in  excess,  irritating  medicines,  such 
as  the  bromids,  iodids,  and  arsenic,  and  corrosive  poisons  such 
as  the  mineral  acids,  corrosive  sublimate,  copper,  carbolic  acid, 
etc.  It  may  also  be  due  to  exposure  to  cold  and  wet  and  the 
infectious  fevers. 


ACUTE    GASTRITIS.  225 

Pathologic  Anatomy. — The  mucous  membrane  of  the  stom- 
ach is  swollen  and  engorged  and  covered  with  a  grayish,  semi- 
transparent  tenacious  mucus  of  alkaline  reaction.  Mucoid 
degeneration  and  cloudy  swelling  of  the  glandular  cells  are 
present.  The  pyloric  region  shows  the  most  marked  inflamma- 
tion. In  toxic  cases,  erosions  are  observed  everywhere  through- 
out the  mucosa;  the  gastric  tubules  are  destroyed  in  great  num- 
bers; and  the  submucous,  muscular,  and  serous  coats  may  show 
decided  destructive  changes. 

Symptoms. — Under  ordinary  circumstances,  acute  gastric 
catarrh  is  manifested  by  loss  of  appetite,  heavily  coated  tongue, 
thirst,  fetor  of  the  breath,  nausea,  sometimes  vomiting,  first  of 
undigested  food,  then  of  viscid  mucus,  and  finally  bilious 
matter,  moderate  fever,  headache,  flashes  of  heat  with  sensa- 
tions of  burning  in  the  palms  of  the  hands  and  soles  of  the  feet, 
abdominal  pain,  tenderness,  and  distress,  eructations,  vertigo, 
fullness  of  the  head,  and  constipation  or  diarrhea.  Herpes  may 
appear  about  the  mouth  toward  the  end  of  an  attack.  Jaun- 
dice may  be  present  as  may  also  slight  fever.  The  urine  is 
scanty  and  contains  urates  and  pigment.  Examination  of  the 
stomach  contents  shows  a  deficiency  in  hydrochloric  acid  and 
an  excess  of  lactic  and  fatty  acids,  mucus,  and  undigested  food.- 
Digestion  is  considerably  prolonged. 

In  toxic  gastritis,  immediately  or  very  shortly  after  the  poison 
is  swallowed  there  ensues  a  deadly  nausea,  followed  by  rapid 
and  persistent  vomiting,  first  of  the  stomach  contents,  after- 
ward shreds  of  mucous  membrane  and  blood  clots.  Anxiety 
and  depression,  a  weak,  rapid  pulse,  slow  and  shallow  respira- 
tion, cold,  clammy  skin,  intense  burning  pain  and  heat  in  the 
epigastrium,  thirst  with  burning  in  the  fauces  and  gullet, 
exhaustive  purging,  shrunken  features,  and  collapse  follow. 

Diagnosis. — Simple  cases  may  resemble  the  onset  of  one  of 
the  infectious  fevers,  but  the  absence  of  other  symptoms  than 
those  referable  to  the  stomach,  within  twenty-four  to  forty- 
eight  hours  will  establish  the  diagnosis.  In  toxic  cases,  the 
history  and  the  sudden  and  severe  symptoms  will  indicate 
poisoning,  and  the  stains  on  the  lips,  mucous  membrane,  face, 

15 


226  ACUTE    GASTRITIS. 

or  clothing  may  determine  the  character  of  the  poison,  for 
instance :  A  blackish  eschar  points  to  sulphuric  acid,  a  yellowish 
eschar  to  nitric  acid,  widespread  softening  and  maceration  of 
the  tissues  to  caustic  potash,  whitish  or  glazed  stains  to  corrosive 
sublimate,  whitish  and  corrugated  stains  to  carbolic  acid,  and 
yellowish  white  scars  changing  to  grayish  brown  to  chromic  acid. 

Prognosis. — In  mild  cases,  the  duration  is  about  one  week 
and  the  termination  is  favorable,  although  complete  recovery 
may  be  slow.  The  toxic  form  is  very  grave.  Many  perish 
from  shock.  In  cases  not  immediately  fatal,  death  may  occur 
from  exhaustion  and  starvation  incident  to  the  destructive 
changes.  Cases  that  eventually  recover  are  always  affected 
with  gastric  disturbances  of  varying  degree. 

Treatment. — The  stomach  should  be  placed  at  rest.  When 
the  stomach  is  overloaded  ipecac  should  be  given  by  the  mouth 
or  apomorphin  hydrochlorid,  gr.  i/8  (0.008  gm.),  should  be 
administered  hypodermically.  If  vomiting  has  already  begun 
large  draughts  of  hot  water  should  be  given.  Active  purga- 
tion by  calomel,  gr.  v  to  x  (0.32  to  0.65  gm.),  and  sodium  bicar- 
bonate, gr.  V  (0.32  gm.),  followed  by  an  ounce  of  magnesium 
sulphate  or  a  full  dose  of  Hunyadi  Janos  water,  is  of  great  value 
in  most  cases.  Fractional  doses  of  calomel  are  sometimes 
preferred.  After  the  stomach  and  bowels  have  been  thoroughly 
emptied,  feeding  should  be  resumed,  beginning  with  the 
most  bland  food.  Nux  vomica,  pepsin,  or  papoid  may  then  be 
administered. 

The  following  is  an  excellent  stomachic  sedative: 

T^.      Sodii  bicarb oiij  12 .  gm. 

Bismuth,    subnitrat 5ij  8.  gm. 

Aq.  chloroformi f  oiij  90.  c.c. 

M.  et  adde 

Aq.  menthse  pip f  Bj  30.  c.c. 

Aq.  lauro-cerasi.  ......  .    fgij  60.  c.c. 

M.  S. — Tablespoonful  four  times  a  day. 

Another  excellent  formula  after  the  acute  symptoms  have 
subsided  is: 


ACUTE    GASTRITIS. 


227 


03  g"l 

15 

c.c. 

30 

c.c. 

15 

c.c. 

30 

c.c. 

i\.      vStrychninae  sulphat gr.ss 

Acid,  hydrochlorici  dil .       f  oiv 

Glycerini f  5j 

Tinct.  card,  comp f  oss 

Aq.  lauro-cerasi f  oj 

M.  S. — One  teaspoonful,  diluted,  four  times  daily. 

In  toxic  gastritis,  morphin  sulphate  should  be  given  hypo- 
dermically  at  once  and  repeated  if  necessary.  Strychnin  and 
atropin  will  be  required  in  most  cases  to  sustain  the  circulation. 
Demulcents  and  milk  and  lime-water  should  be  freely  given. 
Ice  internally  and  locally  affords  great  relief.  Bismuth  sub- 
nitrate,  gr.  XX  to  XXX  (1.3  to  2  gm.),  every  hour  is  beneficial. 
The  stomach  should  be  emptied  of  its  contents  immediately  by 
means    of    an    emetic    (apomorphin    hydrochlorid)    or   lavage. 

In  all  cases  of  poisoning,  the  indications  as  laid  down  by 
Tanner,  are:-i.  Lose  no  time.  2.  Use  the  best  remedy 
obtainable  at  once.  3.  Get  rid  of 
action.  5.  Remedy  the  mischief 
Fight  against  the  tendency  to  death. 

If  seen  early  the  appropriate  antidote  should  be  administered. 
The  following  table  (compiled  chiefly  from  Potter's  Therapeutics, 
Materia  Medica  and  Pharmacy),  will  be  found  of  great  value 
for  ready  reference  in  this  condition. 

Irritant  and  Corrosive  Poisons. 


the    poison.      4.   Stop  its 
already     done.      And     6. 


Poison. 


Antidotes. 


Acid,  carbolic. 


Acid,  oxalic  and  "salts 
of  lemon,"  or  of 
"sorrel." 


Magnesium  or  sodium  sulphate;  alcohol; 
liquor  calcis  saccharatus;  vinegar.  Wash 
out  stomach  with  alcohol  and  water.  Give 
hypodermic  of  apomorphin  hydrochlorid. 

Calcium  carbonate  or  hydrate  (as  lime- 
water,  chalk,  whiting,  wall-plaster,  in 
water),  or  magnesia.  Avoid  potassium 
and  sodium  carbonates  and  bicarbonates. 
Bland  mucilaginous  drinks  and  poultices 
to  the  abdomen. 


228  ACUTE    GASTRITIS. 

Irritant  and  Corrosive  Poisons. — Continued. 


Poison. 


Antidotes. 


Acids,  mineral. 


Alkalies . 


Ammonia 


Arsenic 

Corrosive  sublimate , 


lodin 

Metallic    salts 

Phenol 

Phosphorus 

Silver  nitrate 

Soda,  or  "caustic  pot 
ash."     "Lye." 


Alkalies,  as  sodium  carbonate  or  bicarbon- 
ate, magnesia,  or  chalk,  soap,  whiting, 
wall-plaster,  in  water.  Albumin,  flour, 
milk,  starch,  olive  oil,  to  protect  the 
mucous  membrane.  Avoid  water  in  sul- 
phuric acid  cases. 

Acids,  diluted,  especially  the  vegetable 
acids,  as  vinegar,  lemon- juice,  etc.  Albu- 
min, milk,  gelatin.  Oils  to  protect  the 
mucous  surfaces. 

Vinegar,  lemon-  or  orange-juice,  any  vege- 
table acid,  followed  by  demulcents  to  pro- 
tect the  mucous  surfaces.  When  inhaled, 
give  vapor  of  acetic  or  hydrochloric  acids 
or  chlorin-water  by  inhalation,  the  two 
latter  forming  the  chlorid. 

Freshly  prepared  solution  of  ferric  hydroxid; 
dialyzed  iron;  apomorphin  as  an  emetic. 

Albumin,  white  of  egg  (4  gr.  sublimate 
require  white  of  i  egg),  flour,  milk;  this 
should  be  followed  by  stomach-tube,  or 
emetic. 

Starch,  albumin,  flour,  sodium  or  potassium 
carbonates  and  bicarbonates. 
Albumin,  milk,  magnesia,  starch,  soap. 
Oils  and  other  demulcents.  Sodium  or 
potassium  carbonate  or  bicarbonate.  Five 
per  cent,  solution  of  borax  in  milk.  Lav- 
age of  stomach.      Emetics  and  cathartics. 

See  Acid,  carbolic. 

Potassium  permanganate;  turpentine,  old  and 
acid,  containing  oxygen;  hydrated  mag- 
nesia in  linseed  tea.  Avoid  oils,  fats,  and 
milk. 

Solution  of  common  salt  in  demulcent  drink, 

Olive  oil,  demulcents,  vinegar,  lemon-juice; 
and  stimulants  hypodermically. 


CHRONIC   GASTRITIS.  229 


CHRONIC  GASTRITIS. 


Synonyms. — Chronic  gastric  catarrh;  chronic  dyspepsia. 

Definition. — A  chronic  catarrhal  inflammation  of  the  stomach 
with  thickening  of  the  coats,  enfeeblement  of  the  musculature, 
atrophy  of  the  gastric  glands,  changes  in  the  gastric  juice,  and 
increased  secretion  of  mucus. 

Achylia  gastrica  is  a  term  applied  to  the  absence  of  free  or 
combined  hydrochloric  acid  and  pepsin  and  rennin.  It  is 
often  associated  with  chronic  gastritis,  atrophy,  and  carcinoma, 
but  it  may  also  occur  independently. 

Causes. — Repeated  attacks  of  acute  gastritis;  dyspepsia, 
neglected  or  long-  continued;  habitual  and  excessive  use  of 
spirituous  liquors,  tea,  cofifee,  and  the  free  use  of  ice-water 
during  and  between  meals;  improperly  prepared  and  unsuitable 
food;  irregularity  of  meals  and  imperfect  mastication;  excessive 
tobacco-chewing;  anemia;  diseases  of  the  heart,  lungs,  pleura, 
liver,  or  kidneys,  producing  chronic  congestion  of  the  stomachic 
vessels;  cancerous  or  other  degenerative  diseases  of  the 
stomach. 

Pathologic  Anatomy. — The  mucous  membrane  is  of  a  brown- 
ish or  slate  color,  elevated  into  ridges  from  hypertrophy,  the 
result  of  constant  congestion;  the  peptic  glands  first  increase  in 
size,  then  undergo  granular  change,  resulting  in  atrophy  of 
their  cells.  The  mucous  membrane  is  covered  with  a  thick, 
alkaline,  tenacious  mucus.  The  tubules  may,  in  some  places,  be 
distended  by  secretion,  and  in  other  places  contracted  by  the 
excess  of  connective  tissue  surrounding  them.  Ewald  describes 
the  minute  anatomy  as  that  of  a  parenchymatous  and  intersti- 
tial inflammation,  which  may  lead  to  such  widespread  degenera- 
tion of  the  glandular  elements  so  that  ultimately  scarcely  a 
trace  of  secreting  tissue  remains.  These  changes  may  affect 
the  entire  organ  or  be  limited  to  portions  of  the  stomach; 
they  are  most  marked  at  the  pyloric  end. 

Symptoms. — The  persistent  and  manifold  symptoms  of  indi- 
gestion are  present,  such  as  loss  of  appetite;  disagreeable  feeling 
of  gnawing  and  at  times  fullness  in  the  stomach;  tenderness  in 


230  CHRONIC   GASTRITIS. 

the  epigastrium,  but  slightly  influenced  by  eating;  prominence 
of  the  epigastrium,  from  distention  by  decomposing  gases;  and 
occasional  nausea  and  vomiting  of  undigested  foods  after 
meals,  or  of  colorless  fluid  when  the  stomach  is  empty.  The 
vomitus  often  contains  a  large  amount  of  mucus,  and  its  reac- 
tion may  be  neutral  or  acid;  in  the  latter  event,  the  acidity  is 
due,  not  to  hydrochloric  acid  (which  is  diminished)  but  to 
organic  acids  produced  by  fermentation. 

Early  morning  vomiting  of  glairy  mucus  and  saliva,  coating 
of  the  tongue,  constant  thirst,  burning  at  the  pit  of  the  stomach 
or  under  the  sternum  (heartburn),  pain  after  eating,  and  con- 
stipation are  common.  In  long-standing  cases  the  circulation 
is  feeble;  there  is  depression  of  spirits  often  amounting  to 
melancholia;  and  vertigo  and  sleeplessness  are  present.  Follic- 
ular pharyngitis  often  accompanies  the  condition.  The 
imperfect  digestion  leads  eventually  to  loss  of  flesh.  The  urine 
is  high-colored  and  contains  phosphates,  urates,  and  the  oxalate 
of  lime  in  excess.  An  examination  of  the  gastric  contents  will 
show  a  diminution  in  hydrochloric  acid  and  pepsin,  and  rennin, 
and  a  large  quantity  of  mucus,  and  often  sarcinae  ventriculi. 
In  severe  cases  there  may  be  absence  of  hydrochloric  acid,  pepsin, 
mucus,  and  epithelium;  and  the  gastric  contents  be  made  up 
chiefly  of  undigested  food  and  bacteria. 

Diagnosis. — Chronic  gastritis  may  be  readily  recognized,  if  the 
history  and  symptoms  are  fully  considered.  In  many  instances 
the  stomach  disturbance  is  secondary  to  some  visceral  disease, 
which  may  be  ascertained  by  a  careful  examination. 

Gastric  cancer  may  be  distinguished  by  the  early  absence  of 
hydrochloric  acid,  and  the  presence  of  large  quantities  of  lactic 
acid  and  the  Boas-Oppler  bacillus  in  the  stomach  contents, 
vomiting  of  a  persistent  character,  containing  blood  in  the 
advanced  stages,  enlargement  at  the  pylorus,  dilatation  of  the 
stomach,  and  cachexia. 

Gastric  ulcer  differs  from  chronic  gastritis  in  that  there  is 
hyperacidity,  localized  pain  and  tenderness  worse  after  eating, 
and  hematemesis. 

Dyspepsia   has   to   be    distinguished   from   chronic   gastritis, 


CHRONIC    GASTRITIS. 


231 


and  the  following  table   from   Wheeler  and  Jack   may   aid   in 
diagnosing  between   the   two   conditions: 


Chronic  Gastritis. 


Dysjjepsia. 


Pain  is  often  severe  with  diffuse  e];i- 
gastric  tenderness. 

Fever. — Temperature  sometimes 
slightly  raised. 

Thirst. — Often  a  marked  symptom  . 

Vomiting. — Frequently  occurs  espe- 
cially in  the  morning.  Lactic, 
butyric,  and  acetic  acids  often 
present.  Pain  is  not  usually 
relieved  by  vomiting. 

Causes. — Usually  the  constant  intro- 
duction of  irritants,  such  as  alco- 
hol in  excess,  abuse  of  tea,  mor- 
phin,  etc. 

Tongue,  etc.,  is  furred,  red  at  the  tip 
and  edges.  The  lips  are  cracked, 
and  the  gums  spongy  and  red. 

Morbid  A natomy.  —  Stomach  is 
much  thickened,  the  mucous 
membrane  is  often  much  atro- 
phied and  fibrous  in  structure. 
It  presents  a  rough  mammilated 
appearance  with  suppurating 
points,  localized  vascular  areas, 
and  hemorrhagic  erosions. 
Note. — Though  the  membrane 
is  thickened,  there  is  marked 
atrophy  of  the  glandular  elements. 


Less      severe;       tenderness      is 

usually  absent. 
Not  raised. 

Absent. 

Vomiting  is  not  frequent  ex- 
cept after  certain  foods,  then 
relief  is  obtained. 


See  page  249.  Often  there  is 
no  obvious  cause  and  the  best 
dietetic  treatment  may  fail 
to  cure. 

Tongue  broad,  flabby,  and 
indented  by  the  teeth.  Gums 
are  soft  and  anemic.  Lips 
are  not  usually  fissured. 

In  pure  dyspepsia  these  changes 
are  not  present.  The  mucous 
membrane  may  be  thickened 
and  injected.  The  muscular 
fibers  are  pale,  flabby,  and 
relaxed. 


Prognosis. — With  treatment,  most  of  the  symptoms  may  be 
greatly  relieved  and  in  mild  cases  cure  may  be  affected.      When 


232  CHRONIC   GASTRITIS. 

the  mucous  membrane  has  become  atrophied  the  outlook  be- 
comes unfavorable. 

Treatment. — The  first  indication  is  the  correction  of  the  in- 
digestion, which  is  usually  the  most  pronounced  and  distressing 
symptom;  this  is  accomplished  by  carefully  regulating  the 
amount  and  character  of  the  food  used,  avoiding  fatty,  sacchar- 
ine, and  starchy  articles  or  highly  seasoned  food  or  stimulants. 
A  milk  diet  is  beneficial,  and  to  it  may  be  added  beef  in  small 
amounts,  eggs,  oysters,  and  a  few  fresh  green  vegetables. 
It  must  be  remembered,  however,  that  some  persons  cannot 
take  milk;  in  such  cases,  the  addition  of  lime-water,  some  alka- 
line carbonated  water  (such  as  Vichy)  and  a  pinch  of  salt,  will 
overcome  the  difficulty.  Skimmed  milk,  buttermilk,  or  fer- 
mented milk  may  be  more  palatable  to  the  patient,  at  any  rate 
for  a  time.  If  beef  is  allowed,  it  had  better,  for  a  time,  be  in 
the  form  of  "Salisbury  steaks"  made  of  lean  beef  shaped  into 
flattened  cakes  and  broiled.  This,  or  whatever  other  articles 
of  diet  are  allowed,  should  be  taken  an  hour  or  more  after 
sipping  slowly  a  half  pint  (250  c.c.)  of  water  at  110°  to  150°  F. 
The  hot  water  should  also  be  taken  before  retiring.  The 
patient  should  be  advised  against  overeating  and  also  against 
imperfect  mastication  and  hurrying  over  his  meals. 

The  constipation  should  be  relieved  by  the  use  of  laxative 
mineral  waters,  such  as  Bedford,  Saratoga,  and  Hunyadi  Janos 
waters,  or  an  artificial  Carlsbad  salt,  which  may  be  made  as 
follows:  Sodium  sulphate,  50  parts;  sodium  bicarbonate,  6; 
sodium  chlorid,  3;  take  one  teaspoonful  dissolved  in  a  glass 
of  water. 

Or  the  following  may  be  used: 

I^.      Magnesii  sulphat- gr.  Ix  to  cxx        4  .  to  8  .  gm. 

Sodii  et  potass,  tartrat .  .    gr.  xxx  to  Ix        2  .  to  4.  gm. 

Acid  tartaric gr,  xx  1.3  gm. 

M.  S. — Dissolve  in  a  glass  of  water  and  drink  one  hour  before 
breakfast. 

An  excellent  purgative  and  promoter  of  stomachic  peristalsis 
is; 


CHRONIC    GASTRITIS.  233 

T^.     Fluidextract  cascarae  sagradae.   f  5j  30.C.C. 

Glycerini f  5ss  15.  c.c. 

Tinct.  nucis  vomicae f  §ss  15.  c.c. 

Aq.  chloroformi f  §j  30.  c.c. 

M.  S. — One  or  two  teaspoonfuls  after  meals,  well  diluted. 

For  the  purpose  of  cleaning  the  stomach  of  the  tenacious 
mucus  as  well  as  for  its  stimulating  action  on  the  glands,  lavage 
or  irrigation  of  the  stomach  with  lukewarm  water  is  valuable. 
The  water  may  be  medicated  with  a  solution  of  salt,  sodium 
bicarbonate,  or  boric  acid.  Ewald  considers  the  morning, 
when  the  stomach  is  empty,  the  preferable  time  for  lavage. 

Those  patients  who  object  to  lavage  obtain  relief  from  the 
systematic  drinking  of  1/2  to  i  pint  (250  to  500  c.c.)  of  hot 
water  an  hour  before  meals,  as  mentioned  above. 

The  irritable  condition  of  the  mucous  membrane  is  at  times 
greatly  benefited  by  the  use  of  bromid  of  strontium,  gr.  xv 
(i  gm.),  well  diluted,  before  meals.  For  the  anorexia  in  chronic 
gastritis,  Hemmeter  gives: 

I^.      Strychninae  sulphatis .  .  . .    gr.  1/3  0.02  gm. 

Acidi  hydrochlorici  diluti    ov  20.       c.c. 

Elixir  gentianae    q.  s.  ad    §vj  24.        c.c. 

M.  S. — A  tablespoonful  in  a  wineglass  of  water,  after  meals. 

In  the  presence  of  some  morbid  condition  of  the  mucous 
membrane  the  solution  of  the  'arsenite  of  potassium  (Fowler's 
solution),  nxi  to  ii  (0.06  to  0,12  c.c),  before  meals,  or  bismuth 
subnitrate,  gr,  x  to  xx  (0.65  to  1.3  gni.),  one  hour  before  or 
two  or  three  hours  after  meals  will  be  of  value.  The  following 
combination  will  be  found  very  useful: 

I^.      Sodii  bicarb 5iv  15.  gm. 

Bismuth,  subnitrat 5vj  24.  gm. 

Aquss  chloroformi fSiij  90.  c.c. 

M.  et  adde 

Aquae  lauro-cerasi f  5iij  90.         c.c. 

Strychninae  sulphat gr.  j  .065  gm. 

M.  S. — Two  teaspoonfuls  at  mealtime  in  a  little  water. 


65  gm 

32  c.c. 

32  c.c. 

4 

c.c. 

32 

c.c. 

234  PEPTIC  ulcer;  gastric,  and  duodenal. 

Silver  nitrate,  gr.  1/4  (0.016  gm.),  or  silver  oxid,  gr.  ss  to  j 
(0.032  to  0.065  gm.)  in  pill,  before  meals,  or  dilute  hydrochloric 
acid,  rt\x  to  xv  (0.6  to  i  c.c.)  in  water,  before  meals  may  also 
be  employed.  When  pain  is  severe,  opium,  belladonna,  or 
cocain  may  occasionally  be  required  internally  and  belladonna 
plaster  may  be  applied  over  the  stomach.  If  pain  and  nausea 
are  severe,  the  following  may  be  given.; 

I^.      Bismuthi  carbonatis gf-  x 

Acidi  hydrocyanici  diluti  ....    Tr[v' 

Liquoris  opii  sedativi rr|v 

Mucilaginis  tragacanthae oj 

Aquae  menthae  piperitae  q.  s.  ad    5j 
M.  S. — To  be  taken  half  an  hour  before  food,  or    when  in 
pain. 

To  aid  digestion,  acids,  pepsin,  pancreatin,  papoid,  and  bit- 
ters are  of  value,  the  following  being  an  excellent  prescription^ 

I^.      Pepsini  (cryst.) gr.lx       ^  4.  gm. 

Acid  hydrochlorici  dil.  ..foiv  15.  c.c. 

Glycerini f  5iv  1 5 .  c.c. 

Strychninae  sulphat gr.  ss  .032  gm. 

Aquae  chloroformi,  q.s. ad   foiij  ad  90.  c.c. 

M.  S. — One  teaspoonful  at  mealtime  in  a  little  water. 

In  addition  to  medicinal  measures,  there  should  be  prescribed 
mental  and  physical  rest,  gentle  systematic  exercises,  change 
of  environment,  etc. 


PEPTIC  ULCER;  GASTRIC,  AND  DUODENAL. 

Synonym. — Simple  or  round  ulcer. 

Definition. — A  round  or  oval,  usually  single,  sharply  de- 
fined loss  of  tissue  involving  the  mucous  membrane  and  one 
or  more  layers  of  the  wall  of  the  stomach  or  duodenum;  char- 
acterized by  gastric  pain,  disorders  of  digestion,  hyperacidity, 
and  vomiting  of  blood. 

Causes. — The  important  etiologic  factors  are  early  adult 
life,  female  sex  (for  gastric  ulcer),  traumatism,  chlorosis,  and 


PEPTIC  ulcer;  gastric,  and  duodenal.  235 

anemia.  The  exciting  cause  may  be  an  embolus  or  thrombus, 
or  self -digestion  of  the  stomach  wall.  Two  prime  factors  are 
said  to  be :  ( i )  feeble  nutrition  of  part  of  the  mucous  membrane ; 
and  (2)  the  action  on  this  area  of  an  excessively  acid  gastric 
juice,  by  which  the  mucous  membrane  is  "  digested  out."  In  the 
duodenum  it  occurs  more  frequently  in  males,  and  is  sometimes 
associated  with  extensive  superficial  burns,  and  tuberculosis. 

Pathologic  Anatomy. — In  the  majority  of  cases  the  ulcer  is 
solitary  and  is  situated  on  the  posterior  wall  of  the  stomach 
near  the  pylorus;  or  in  the  first  part  of  the  duodenum,  within 
I  1/2  inches  of  the  pylorus.  In  a  typical  case  there  is  a  circular 
hole,  with  a  sharp  border  in  the  mucous  coat,  the  sides  converging 
in  the  muscular  coat,  coming  to  a  point  in  the  serous  coat,  thus 
forming  a  funnel-shaped  lesion.  This  appearance  is  most 
marked  in  recent  cases.  As  the  ulcer  advances  it  becomes 
elliptical  and  irregular,  varying  from  i  /4  to  1 1 2  inch  in  diame- 
ter. The  edges,  however,  seldom  become  irregular.  Perforation 
.may  occur.  Blood-vessels  are  constantly  eroded,  producing 
profuse  hemorrhage  and  subsequent  hematemesis.  Connective 
tissue  replaces  the  ulcerated  area  in  the  process  of  healing. 

Symptoms. — Indigestion  and  its  various  manifestations  are 
commonly  present.  The  characteristic  symptoms  are  pain, 
localized  tenderness,  vomiting,  hematemesis,  hyperacidity, 
and  sometimes  an  enlargement  in  the  region  of  the  pylorus. 
The  pain  is  paroxysmal  in  character,  comes  on  in  from  ten  to 
thirty  minutes  after  eating  but  may  be  delayed  for  two  or 
three  hours,  and  is  aggravated  by  the  taking  of  food,  especially 
hot,  cold,  indigestible,  or  spicy  substances.  While  usually 
located  in  the  "pit"  of  the  stomach  it  may  radiate  to  the  back 
and  limbs.  A  burning,  gnawing  pain  may  also  be  present 
between  the  paroxysms  of  gastralgia.  Tenderness  on  pressure 
is  rather  constant,  and  patients  wear  the  waist-band  rather 
low;  it  usually  may  be  elicited  at  a  point  an  inch  or  two  above 
the  umbilicus.  Pressure  must  be  made  with  care,  or  per- 
foration may  occur.  Vomiting  is  common.  It  may  appear 
immediately  after  eating,  when  the  ulcer  is  near  the  cardiac 
'orifice,  but  when  located  near  the  pylorus  it  usually  comes  on 


236  PEPTIC  ulcer;  gastric,  and  duodenal. 

an  hour  after  eating.  The  vomitus  is  usually  very  acid,  and 
consists  of  undigested  food  and  mucus.  Hemorrhage  into  the 
stomach  from  erosion  of  a  blood-vessel  causes  vomiting  of 
large  quantities  of  bright  red  blood  and  the  passage  of  dark 
blood  from  the  bowels ;  such  a  hemorrhage  is  quite  a  char- 
acteristic symptom  of  ulcer  of  the  stomach.  It  occurs  in  about 
50  per  cent,  of  cases.  Examination  of  the  stomach  contents 
will  show  an  increase  in  the  hydrochloric  acid.  Anemia,  loss 
of  weight,  anorexia,  and  general  failing  of  health  accompany 
the  condition.  The  condition  is  often  latent,  presenting  no 
symptoms  during  life;  a  sudden  and  fatal  hemorrhage  (hema- 
temesis)   may  occur,   and  the  ulcer  be  found  at  the  autopsy. 

Diagnosis. — Gastralgia  resembles  gastric  ulcer  as  regards  hy- 
peracidity and  the  paroxysmal  pains.  It  differs  in  the  absence 
of  dyspeptic  symptoms  between  the  attacks,  hematemesis, 
and  localized  tenderness  and  enlargement.  Von  Leube  has 
shown  that  the  application  of  an  electric  current  during  diges- 
tion causes  a  cessation  of  pain  in  gastralgia,  but  not  in  gastric 
ulcer  and  cancer. 

Gastric  cancer  may  be  distinguished  from  gastric  ulcer  in 
that  it  occurs  at  a  later  period  in  life,  has  a  more  rapid  course, 
the  cachexia  and  emaciation  are  more  prominent,  the  pain  is 
more  constant,  the  growth  is  palpable,  the  vomit  has  a  "  coffee- 
grounds"  appearance,  and  there  is  absence  of  hydrochloric 
acid  and  presence  of  lactic  acid. 

Intercostal  neuritis  accompanying  chronic  gastritis  may 
lead  to  an  error  in  diagnosis,  but  the  absence  of  localized  tender- 
ness above  the  umbilicus,  hyperacidity  of  the  gastric  contents, 
and  hematemesis  will  serve  to  make  a  distinction. 

Hyperchlorhydria  is  attended  only  by  an  increase  in  the  hydro- 
chloric acid  and  pain  which  is  relieved  by  albuminous  food. 
The    other    symptoms    common   to    gastric   ulcer   are    absent. 

The  gastric  crises  of  locomotor  ataxia  are  sometimes  very 
similar  to  the  pains  of  gastric  ulcer;  but  the  lightning  pains, 
ocular  symptoms,  and  absence  of  knee-jerks  soon  manifest 
themselves   in  the  former  disease. 

The  differentiation  hetiveen  gastric  and  duodenal  ulcer  is  often 


PEPTIC  ulcer;  gastric,  and  duodenal.  237 

impossible.  The  latter  maybe  suspected:  (i)  If  the  pain  oc- 
curs in  two  to  four  hours  after  eating,  and  is  located  in  the  right 
hypochondrium ;  (2)  if  there  is  a  hemorrhage  from  the  bowel 
rather  than  an  hematemesis;  (3)  jaundice  is  more  frequent  in 
duodenal  ulcer. 

Prognosis. — Usually  the  ulcer  is  slow  in  forming  and  runs  a 
very  chronic  course,  the  average  duration  being  about  one 
year.  Occasionally  it  may  develop  very  suddenly.  It  may 
terminate  in  perforation  (6  per  cent.),  peritonitis,  fatal  hemor- 
rhage, or  recovery  with  cicatricial  formations.  The  mortality 
varies  according  to  different  observers  from  10  to  30  per  cent. 
With  proper  treatment  recoveries  are  frequent.  Relapses  are 
not  uncommon  occurrences. 

Treatment. — The  patient  should  be  placed  at  rest  in  bed. 
The  diet  should  consist  of  only  the  most  bland  food,  preferably 
milk  (i  or  2  ounces  every  two  hours)  and  lime-water,  beef- 
juice,  egg-albumin,  or  skimmed  milk.  When  feeding  by  the 
mouth  induces  too  much  irritation,  resort  should  be  made 
to  rectal  alimentation.  An  enema  made  up  of  4  ounces  of 
milk,  2  eggs,  a  very  small  quantity  of  salt,  and  3  drops  of  the 
tincture  of  opium,  the  entire  mixture  being  predigested  by 
pancreatin,  is  very  valuable  in  this  connection. 

Severe  hemorrhage  will  indicate  the  injection  of  warm  normal 
salt  solution  into  the  rectum  or  hypodermically,  and  the  admin- 
istration of  10  drops  of  adrenalin  solution  (i  to  1,000).  Strych- 
nin, nitroglycerin,  and  ammonia  may  be  given  to  sustain  the 
heart  at  this  period.  Ergot,  acetate  of  lead,  gr.  i  to  ii  (0.065  "to 
0.2  gm.),  gelatin,  tannic  acid,  gr.  xv  (i  gm.),  and  persulphate 
or  iron,  gr.  1/4  to  1/2  (0.0165  to  0.033  g^-).  ^^^  ^-Iso  advised  to 
control  the  hemorrhage.  An  ice-bag  over  the  stomach  and 
small  pellets  of  ice  internally  may  be  of  value.  Feeding  by 
the  mouth  should  be  suspended  when  there  is  hematemesis. 

The  hyperacidity  may  be  overcome  by  large  doses  of  bicar- 
bonate of  sodium  and  calcined  magnesia  every  four  hours. 
Bismuth  subnitrate  and  belladonna  may  be  useful.  In  the 
presence  of  constipation,  Carlsbad  salt  should  be  employed. 
For  relief  of  the  pain,  morphin  may  be  necessary. 


238  CANCER  OF  THE  STOMACH. 

The  medicines  of  special  value  in  this  condition  are  Fowler's 
solution,  Tt^i  to  ii  (0.06  to  0.13  c.c),  every  five  hours;  subnitrate 
of  bismuth,  gr.  xx  to  xxx  (1.3  to  2  gm.),  combined  with  sodium 
bicarbonate,  gr.  v  (  0.32  gm.),  three  times  daily;  silver  nitrate, 
gr.  1/4  to  1/3  (0.016  to  0.022  gm.)  every  four  hours;  and  silver 
oxid,  gr.  ss  (0.032  gm.).  Iron  and  arsenical  preparations  are 
indicated  for  the  constant  anemia. 

I^.     Ferri  albuminatis g^-  ij  -13     gn^- 

Sodii    arsenat. gr.  1/20  .003  gm. 

M.     Ft.  pil.  or  capsule. 
S. — One  three  times  daily. 

The  occurrence  of  perforation  requires  prompt  surgical  inter- 
vention. Operative  treatment  has  also  been  advised  for  the 
cure  of  cases  of  nonperforating  ulcer  in  which  the  hemorrhages 
recur,  or  in  which  there  has  been  a  copious  single  hemorrhage. 

CANCER  OF  THE  STOMACH. 

Synonyms. — Gastric  cancer;  gastric  carcinoma. 

Definition. — A  malignant  growth,  occurring  for  the  most  part 
at  the  pyloric  extremity  of  the  stomach,  making  constant  prog- 
ress, destroying  the  gastric  tissues  and  infecting  the  lymphatic 
glands;  characterized  by  disorders  of  digestion,  pain,  vomiting, 
marked  anemia  and  cachexia,  and  terminating  in  all  cases  by  the 
death  of  the  patient. 

Causes. — Cancer  of  the  stomach  usually  develops  in  patients 
past  forty  years  of  age.  The  sexes  are  about  equally  affected. 
Heredity  is  said  to  be  a  factor  in  some  cases  and  prolonged 
irritation  such  as  accompanies  the  scars  of  old  ulcers  and  chronic 
gastritis  may  be  a  predisposing  cause. 

Pathologic  Anatomy. — Next  to  the  uterus  the  stomach  is  the 
most  frequent  site  of  cancer.  The  growth  is  nearly  always  pri- 
mary; though  secondary  cancer  of  the  stomach  may  occasionally 
occur.  Following  Tyson:  "  Every  variety  of  cancer  is  found  in 
the  stomach,  in  the  following  order  of  frequency:  i.  Cylinder- 
celled  epithelioma,  most  frequent  at  the  pylorus.  2.  Medullary 


CANCER  OF  THE  STOMACH.  239 

or  soft  cancer,  most  frequent  in  the  smaller  curvature.  3. 
Scirrhtis,  at  the  pylorus  and  in  the  smaller  curvature,  causing, 
especially,  stenosis  of  the  pyloric  orifice.  4.  Colloid,  diffuse 
infiltration  with  a  tendency  to  spread  to  the  peritoneum  and 
adjacent  organs.  5.  Melanotic.  6.  Squamous  epithelioma,  near 
the  cardia. 

"  All  the  forms  start  from  the  gland  cells  of  the  mucous  mem- 
brane. The  medullary  variety  is  prone  to  ulcerate  and  to  form 
extensive  fungoid  ulcerated  surfaces,  from  which  there  may  or 
may  not  be  hemorrhage.  It  may  be  associated  with  scirrhus. 
While  nodular  outgrowths  are  usual,  the  cancerous  tissue  may 
infiltrate  the  walls,  producing  diffuse  thickening."  About  80 
per  cent,  of  gastric  cancers  are  found  at  the  pylorus.  Those 
portions  of  the  stomach  remote  from  the  growth  are  compara- 
tively healthy.  The  growth  usually  begins  in  the  tubules. 
The  lym^phatic  glands  adjacent  to  the  stomach  enlarge  as  the 
growth  progresses  and  secondary  cancers  result. 

The  condition  may  give  rise  to  dilatation  of  the  stomach,  or 
to  reduction  in  size  of  the  stomach  with  dilatation  of  the  esopha- 
gus; the  stomach  may  be  altered  in  shape,  or  displaced;  adhe- 
sions may  occur  with  adjacent  organs  or  with  the  anterior 
abdominal  wall;  perforation  and  peritonitis  may  also  result. 

Symptoms. — The  manifestations  of  indigestion  are  present 
from  the  onset.  The  majority  of  cases  have  vomiting,  occur- 
ring immediately  after  eating,  if  the  disease  is  at  the  cardiac 
orifice,  and  some  hours  after  if  located  at  the  pylorus;  if  much 
dilatation  of  the  stomach  develops,  the  vomiting  occurs  after 
several  days.  The  rejected  matter  is  food  in  various  stages  of 
digestion,  associated  frequently  with  black  grumous  masses  of 
altered  blood  and  tissues.  Hematemesis  is  frequent,  rarely 
profuse,  usually  oozing  of  blood  altered  into  a  dark  brown  or 
black  color — "  cofifee-ground"  vomit — in  which  Teichmann's 
hemin  crystals  may  be  obtained;  or  the  oozing  blood  passes  into 
the  intestinal  canal,  causing  tarry  stools.  The  blood  is  some- 
times so  small  in  quantity  that  a  microscopic  or  chemical 
examination  is  required  to  discover  it. 

Absence  of  hydrochloric  acid  in  the  stomach  is  a  very  constant 


240  CANCER   OF    THE    STOMACH. 

observation  in  gastric  cancer.  Boas  and  Stewart  (D.  D.),  in 
1895,  found  by  the  use  of  the  test-meal  (flour  soup)  that  lactic 
acid  was  always  present  in  gastric  cancer,  and  they  were  unable 
to  find  this  acid  in  any  other  stomach  condition.  The  Boas- 
Oppler  bacillus  is  also  present. 

Pain  is  constant,  but  is  dull  and  heavy  in  character,  increased 
by  pressure  and  food,  and  may  radiate  to  the  back.  A  tumor 
is  found  in  three-fourths  of  the  cases  in  the  epigastric  region 
which  does  not  move  with  inspiration.  Edema  of  the  ankles  is 
a  common  phenomenon  in  gastric  cancer,  occurring  as  early 
as  the  third  month  and  may  proceed  to  general  anasarca. 
Marked  anemia,  debility,  emaciation,  and  cachexia  are  constant 
symptoms.  Jaundice  frequently  occurs  and  the  liver  may  be 
enlarged.  There  is  involvement  of  the  lymphatic  glands  in 
the  supraclavicular  and  inguinal  regions  particularly.  All 
the  symptoms  of  gastric  dilatation  (page  242)  are  present.  The 
urine  may  contain  excess  of  indican,  and  is  sometimes  albumin- 
ous ;  and  there  may  be  irregular  fever. 

Diagnosis. — The  age,  history,  the  presence  of  a  palpable 
tumor,  hematemesis  of  "  coffee-ground"  material,  the  absence  of 
free  hydrochloric  acid,  and  the  presence  of  lactic  acid  and  Boas- 
Oppler  bacillus  in  the  stomach  contents,  and  the  cancerous 
cachexia  are  the  important  points  in  the  diagnosis. 

Chronic  gastric  catarrh  is  characterized  only  by  aggravated 
dyspepsia  and  possesses  none  of  the  distinctive  features  of 
gastric  cancer. 

Gastric  ulcer  differs  from  gastric  cancer  in  the  age  of  the  pa- 
tient, the  character  of  the  pain,  the  hemorrhage,  and  the  stom- 
ach contents. 

Cancer  of  the  pancreas  is  generally  attended  by  jaundice  and 
diarrhea  with  fatty  or  oily  stools. 

Pernicious  anemia  has  no  tumor,  less  cachexia,  and  a  more 
pronounced  diminution  in  the  number  of  the  red  blood  cells; 
the  latter  often  fall  below  1,000,000  to  the  cubic  millimeter  in 
anemia,  while  in  gastric  cancer  they  rarely  fall  below  2,000,000. 
As  F.  P.  Henry  tersely  puts  it:  "In  cancer  of  the  stomach  the 
reduction  in  the  number  of  red  corpuscles  does  not  keep  pace 


CANCER  OF  THE  STOMACH.  241 

with  the  cachexia;  in  anemia  the  cachexia  does  not  keep  pace 
with  the  destruction  of  red  corpuscles." 

Abdominal  tumors  of  other  structures  differ  in  that  most  of 
them  in  this  region  move  on  inspiration.  Aneurysm  of  the  ab- 
dominal aorta  is  distinguished  by  its  expansile  pulsation.  A 
pulsation  may  be  communicated  to  a  scirrhus  at  the  pylorus,  but 
if  the  patient  is  directed  to  rest  upon  the  hands  and  feet,  the 
gastric  tumor  falls  away  from  the  aorta  and  the  pulsation  ceases. 

Prognosis. — The  disease  is  invariably  fatal;  sometimes  an 
early  recognition  of  the  disease  followed  by  prompt  and  com- 
plete removal  by  a  competent  surgeon  may  prolong  life. 

Treatment. — The  treatment  is  unsatisfactory  and  is  directed 
largely  toward  maintaining  the  patient's  strength  by  suitable 
foods.  Ordinary  diet  soon  becomes  inadequate  and  irritating, 
and  predigested  foods  have  to  be  used.  Peptonized  milk  may 
be  prepared  by  adding  5  gm.  of  extract  of  pancreas  and 
15  gr.  of  sodium  bicarbonate  to  a  pint  of  milk,  placing 
the  mixture  in  a  compartment  at  a  temperature  of  100°  F., 
from  which  it  is  removed  in  one  hour.  Peptonized  beef, 
peptonized  eggs,  and  similar  foods  may  be  employed.  Should 
the  stomach  become  unretentive,  or,  in  the  presence  of  other 
contra-indications,  resort  should  be  had  to  rectal  alimentation. 
The  administration  of  dilute  hydrochloric  acid  aids  digestion 
and  prevents  fermentation;  and  much  has  been  claimed  for 
condurango : 

]^.      Strychnine  sulphat gr.  ss  .032  gm. 

Acid,  hydrochlor.  dil.  .  .  .    f  5iv  15.  c.c. 

Inf.  condurango.  .q.  s.  ad  fSviij    ad'   240.  c.c. 

M.  S. — Tablespoonful  before  meals,  diluted. 

For  pain,  morphin,  or  the  following  recommended  by  Osier: 

I^.      Morphinae  sulphat. gr.  1/8  .008  gm. 

Sodii  bicarb gr-  v  .3       gm. 

Bismuth,  subnitrat gr.  x  ,6       gm. 

M.  S. — Repeated  p.  r.  n. 

Fetor  of  the  breath  may  be  relieved  to  some  extent  by  car- 
bolic acid,  gr.  1/4  to  1/3  (0.016  to  0.022  gm.),  or  purified  animal 
16 


242  GASTRIC    DILATATION. 

charcoal,  gr.  X  to XXX  (0.65  to  2  gm.).  (And  seepage  209.)  Wash- 
ing out  of  the  stomach  an  hour  before  breakfast  will  produce 
benefit  by  removing  the  retained  and  fermented  material  in  that 
viscus,  but  it  is  a  dangerous  procedure,  and  in  the  presence  of 
ulceration  perforation  may  be  produced.  Stimulants  should 
be  avoided. 

Surgical  treatment  has  been  of  value  in  some  cases. 

GASTRIC  DILATATION. 

Synonym. — Gastrectasis,  or  gastrectasia. 

Definition. — An  abnormal  and  permanent  increase  in  the 
capacity  of  the  stomach,  with  the  walls  either  hypertrophied 
or  decreased  in  thickness;  characterized  by  pronounced  indi- 
gestion, vomiting  of  partly  digested  and  partly  decomposed 
food  at  intervals  of  a  day  or  two,  and  noisy  moving  of  flatus 
within  the  abdomen  (borborygmus). 

Causes. — Stenosis  of  the  pylorus  such  as  results  from  cancer, 
cicatricial  contraction,  hypertrophy  of  the  pylorus,  and  the  pres- 
sure of  abdominal  tumors  is  the  most  common  cause.  It  may 
result  from  relaxation  of  the  stomach  walls  such  as  follows 
habitual  overdistention  from  excessive  eating  or  drinking,  and 
anemia.  General  anesthesia  (particularly  chloroform)  seems  to 
favor  its  production. 

Pathologic  Anatomy. — The  entire  organ  is  dilated  and  its 
muscular  wall  is  hypertrophied  in  pyloric  obstruction;  but  in 
atonic  dilatation,  the  muscular  layer  is  thinner  than  normal, 
paler  in  color,  and  presents  signs  of  fatty  degeneration.  The 
mucous  membrane  is  also  pale,  thin,  anci  without  rugse. 

Symptoms. — The  characteristic  feature  of  gastric  dilatation  is 
the  vomiting  which  occurs  long  after  meals,  often  at  intervals  of 
several  days.  The  vomitus  is  large  in  amount,  and  consists  of 
undigested  and  fermented  food  and  a  turbid  liquid.  It  con- 
tains yeast  cells  and  other  low  forms  of  plant  life.  In  addition 
to  vomiting,  the  symptoms  of  chronic  gastritis  and  of  the 
affection  to  which  the  dilatation  is  due  are  very  prominent. 
Constipation  is  common. 


GASTROPTOSIS.  243 

Physical  signs  of  gastric  dilatation  are:  on  inspection,  abnor- 
mal prominence  of  the  whole  epigastric  region,  with  a  tumor  in 
the  pyloric  region  which  seems  to  be  connected  with  the  stom- 
ach; percussion,  if  empty,  tympanitic  note  having  a  metallic 
quality,  extending  to  or  below  the  umbilicus;  if  the  stomach 
be  filled,  high-pitched  bat  note;  auscultation,  splashing  and 
rumbling  sound,  the  succussion  sound  being  distinct  if  the  body 
be  shaken. 

Diagnosis. — The  peculiar  vomiting  and  the  physical  signs  to- 
gether with  the  history  will  aid  greatly  in  making  a  diagnosis. 
The  outline  of  the  stomach  may  be  mapped  out  by  physical 
examination  by  inflating  the  organ  with  air  or  filling  it  with 
liquid.  The  rv-ray  may  also  be  used.  A  bismuth  solution  is 
given  to  produce  a  shadow  in  the  stomach  after  which  a  skia- 
graph is  taken.  According  to  Boas,  dilatation  is  present  when 
the  greater  curvature  is  below  the  umbilicus  and  when  the 
greatest  vertical  diameter  of  the  stomach  is  from  10  to  14  cm. 
(4  to  5    1/2  inches). 

Prognosis. — Recovery  is  impossible  in  malignant  pyloric  ob- 
struction, but  in  atonic  dilatation  considerable  symptomatic 
relief  may  be  afforded. 

Treatment. — A  "dry  diet"  should  be  used  exclusively  and 
only  small  quantities  should  be  given  at  a  time.  Fluid  should 
be  administered  by  rectal  enemas.  Washing  out  of  the  stom- 
ach every  night  before  retiring  should  be  performed.  An 
abdominal  bandage  may  be  of  benefit.  Drugs,  such  as  dilute 
hydrochloric  acid,  nitrohydrochloric  acid,  pepsin,  nux  vomica, 
creasote,  charcoal,  salol,  and  bismuth,  or  betanaphtol  may  be 
employed  to  prevent  fermentation.  Surgical  treatment, 
pyroplasty  and  gastroenterostomy,  may  be  considered  in  or- 
ganic pyloric  obstruction. 

GASTROPTOSIS. 

Definition. — A  displacement  of  the  stomach  downward,  as- 
sociated with  prolapse  of  the  bowel  (enteroptosis  or  Glenard's 
disease)  and  often  the  prolapse  of  the  kidney  (nephroptosis). 


244  GASTROPTOSIS. 

Causes. — The  condition  is  predisposed  to  by  imperfect  develop- 
ment of  the  abdominal  and  other  muscles  and  by  their  early 
loss  of  tension  with  wasting.  Women  are  most  often  affected. 
Frequent  pregnancies,  wearing  tight  corsets,  or  other  unyield- 
ing garments,  and  occupations  which  favor  stooping  postures, 
such  as  sewing,  tailoring,  shoemaking,  etc.,  are  important 
factors  in  its  production.  Relaxation  of  the  abdominal  walls 
and  loss  of  abdominal  fat  from  any  cause  may  give  rise  to  dis- 
placement of  the  stomach. 

Anatomic  Conditions. — The  transverse  colon  is  the  first 
organ  to  prolapse,  and  is  soon  followed  by  the  ascending  colon. 
The  stomach  is  tilted,  its  lower  border  reaching  below  the 
umbilicus,  while  its  lesser  curvature  lies  between  the  ensiform 
cartilage  and  the  umbilicus.  In  some  cases  the  pyloric  end  is 
down  to  or  below  the  umbilicus,  without  so  much  prolapse  of 
the  fundus.  The  right  kidney  is  displaced  and  often  floating 
or  movable.  The  left  kidney  is  less  often  displaced.  Any  or 
all  of  the  conditions  named  may  be  associated  with  any  of  the 
organic  gastric  conditions. 

Symptoms. — The  patient  complains  of  dyspepsia,  abdominal 
distress  and  pain  after  eating,  eructations  of  gases,  anorexia, 
various    nervous    symptoms,    weakness,    and    constipation. 

Physical  phenomena. — In  the  standing  position  the  lower 
part  of  the  abdomen  projects  and  the  upper  part  sinks  in.  In 
the  recumbent  position  the  abdomen  shows  a  lateral  extension. 
Aortic  piilsation  is  frequent.  There  is  often  "  a  ridge  lying 
across  the  abdomen"  to  be  determined  by  palpation.  Glenard 
termed  this  ridge  the  "cordecolique  transverse"  and  thought 
it  was  due  to  a  prolapse  of  and  partial  occlusion  of  the  trans- 
verse colon.  Other  observers  think  it  is  the  pancreas  that 
is  felt  on  account  of  the  prolapse  of  the  transverse  colon.  In- 
flation of  the  stomach  often  detects  its  prolapsed  position 
with  a  lowered  gastric  splashing.  The  x-rsiy,  with  the  aid  of  a 
bismuth  subnitrate  solution,  will  determine  the  location  of 
the  organ. 

Treatment. — Abdominal  bandages  or  some  mechanical  appa- 
ratus may  be  worn  to  help  maintain  the  organ  in  place,  but  the 


HEMATEMESIS.  245 

benefit  they  produce  is  not  marked.  Surgical  intervention 
sometimes  relieves  the  condition.  In  all  cases,  measures 
directed  toward  improving  the  general  health  should  be 
employed.  Lavage  is  useful  in  that  it  serves  to  prevent  dilata- 
tion of  the  stomach. 


HEMATEMESIS. 

Synonyms. — Gastric  hemorrhage;  gastrorrhagia ;  hemorrhage 
of  the  stomach. 

Causes. — Hematemesis  may  be  due  to  ulcer,  cancer,  cir- 
rhosis or  congestion  of  the  liver,  scurvy,  purpura,  hemophilia, 
malaria,  congestion  of  the  spleen,  chronic  heart  disease,  vicar- 
ious menstruation,  traumatism,  yellow  fever,  toxic  gastritis, 
or  rupture  of  an  aneurysm  into  the  stomach.  The  condition  is 
sometimes  feigned  by  hysterical  patients  who  first  swallow  blood 
or  some  other  colored  liquid,  and  then  vomit  it. 

Symptoms. — The  principal  symptom  is  blood,  of  varying 
qua,ntity,  in  the  vomit.  In  ulcer  of  the  stomach  it  is  bright 
red,  but  in  cancer,  the  most  common  cause,  it  has  the  char- 
acteristic "coffee-grounds"  appearance,  being  dark,  mixed 
with  the  food,  and  of  acid  reaction.  If  the  hemorrhage  is 
profuse,  blood  will  appear  in  the  stools.  There  are  also  present 
at  the  time  of  the  loss  of  blood  pallor,  weakness,  ringing  in 
the  ears,  faintness,  and  a  sinking  feeling  at  the  pit  of  the 
stomach, 

"Occult  blood,''  or  ''occult  hemorrhage''  is  the  name  given  to 
minute  quantites  of  blood  found  in  the  feces  by  the  most  delicate 
tests  (microscopic  or  chemical) ;  it  is  sometimes  found  in  ulcer 
and  cancer  of  the  stomach. 

Diagnosis. — The  chief  condition  from  which  hematemesis 
is  to  be  distinguished  is  hemoptysis  (bleeding  from  the  lungs). 
The  following  table  shows  the  chief  differences: 


246 


GASTRALGIA. 


Hematemesis. 

Hemoptysis. 

I. 

Previous   history  of  gastric,    he- 

I. 

Previous  history  of  pulmo- 

patic, or  splenic  disease. 

nary  troubles. 

2. 

Blood  is   vomited. 

2. 

Blood  is  coughed  up. 

3- 

Blood    is    dark    colored   and  not 

3- 

Blood    is  frothy  and    bright 

frothy. 

red. 

4- 

Blood  may  be  mixed  with  food.  . 

4- 

Blood  may  be  mixed  with 
sputa. 

5- 

Giddiness    or    faintness    usually 

5- 

Sensation  of  tickling  in  the 

precede  vomiting. 

throat  usually  precedes. 

6. 

Nausea    and    weight    in    epigas- 

6. 

Dyspnea    and   pains  in  the 

trium. 

chest. 

7- 

Often  followed  by  melena  (black 

7- 

Is  not  usually  succeeded  by 

tarry  stools). 

melena. 

Prognosis. — Except  in  case  of  a  ruptured  aneurysm,  hema- 
temesis is  seldom  the  direct  cause  of  death.  Hemorrhage  from 
the  stomach  in  the  course  of  gastric  ulcer  or  cancer,  hepatic 
cirrhosis,  hemophilia,  and  the  infectious  fevers  is  an  unfavorable 
sign.      The  outcome  depends  entirely  on  the  underlying  cause. 

Treatment. — Rest  in  bed  is  absolutely  necessary  and  food 
should  be  temporarily,  withheld.  Pellets  of  ice  may  be  swal- 
lowed and  ice-bags  should  be  placed  over  the  stomach  and 
along  the  spine.  In  some  cases  hot  water  is  equally  beneficial. 
Morphin  and  ergotin  should  be  given  hypodermically.  Mon- 
sel's  solution,  nxi  to  v  (0.06  to  0.3  c.c),  diluted,  or  adrenalin 
chlorid  (i  to  1000),  ttlx  (0.6  c.c),  may  be  administered  by  the 
mouth  for  its  hemostatic  efifect.  Tannic  acid,  lead  acetate,  and 
gelatin  may  also  be  employed  for  the  same  purpose.  Shock 
should  be  treated  as  under  ordinary  circumstances.  The  condi- 
tion underlying  the  gastric  hemorrhage  should  receive  attention. 

GASTRALGIA. 

Synonyms. — Cardialgia;  gastrodynia;  stomachic  colic;  neu- 
ralgia of  the  stomach. 

Definition. — A  painful  condition  of  the  stomach,  induced  by 


GASTKALGIA.  247 

various  forms  of  irritation;  characterized  by  violent  paroxysms 
of  gastric  pain  and  associated  with  feeble  cardiac  action  and 
symptoms  of  collapse,  but  independent  of  disturbance  of  the 
gastric  functions. 

Causes. — The  affection  belongs  to  the  group  of  neuralgias. 
The  most  important  factor  in  its  causation  is  general  nervous 
depression  or  neurasthenia;  other  causes  are  gastric  cancer  or 
ulcer,  malaria,  rheumatic  or  gouty  diathesis,  syphilis,  anemia, 
and  certain  articles  of  diet.  It  occurs  in  chronic  nervous 
affections  as  the  so-called  "  gastric  crises. "  It  is  more  frequently 
observed  in  women  than  men,  and  may  arise  from  worry, 
menstrual  disorders,  sexual  excesses,  and  the  abuse  of  tobacco, 

Symptoms. — Romberg's  description  of  an  attack  may  be 
quoted:  "Suddenly,  or  after  a  feeling  of  pressure  at  the  pre- 
cordium,  there  is  severe  griping  pain  in  the  stomach,  usually 
extending  to  the  back,  with  a  feeling  of  fainting,  a  shrunken 
countenance,  cold  hands  and  feet,  and  an  intermittent  pulse. 
The  pain  becomes  so  excessive  that  the  patient  cries  out.  The 
epigastrium  is  either  puffed  out  like  a  ball,  or  retracted,  with 
tension  of  the  abdominal  walls.  There  is  often  pulsation  in 
the  epigastrium.  External  pressure  is  well  borne,  and  not  un- 
frequently  the  patient  presses  the  pit  of  the  stomach  against 
some  firm  substance,  or  compresses  it  with  his  hands.  Sym- 
pathetic pains  often  occur  in  the  thorax,  under  the  sternum,  and 
in  the  esophageal  branches  of  the  pneumogastric,  while  they  are 
rare  in  exterior  of  the  body.  The  attack  lasts  from  a  few  minutes 
to  half  an  hour  or  longer;  then  the  pain  gradually  subsides,  leav- 
ing the  patient  much  exhausted;  or  else  it  ceases  suddenly,  with 
eructation  of  gas  or  watery  fluid,  or  with  vomiting  and  with  a 
gentle  soft  perspiration,  or  with  the  passage  of  reddish  urine." 

Diagnosis. — Myalgia  of  the  abdominal  muscles  is  distin- 
guished by  tenderness  on  pressure  over  the  affected  area,  more 
constant  pain,  and  the  absence  of  symptoms  directly  referable 
to  the  stomach. 

Gastric  cancer  is  differentiated  by  the  age,  course,  history, 
hematemesis,  cachexia,  tumor,  anemia,  and  the  constant  char- 
acter of  the  pain. 


248  GASTRALGIA. 

Gastric  tdcer  is  attended  by  localized  pain  and  tenderness,  ag- 
gravated by  food  and  external  pressure,  hematemesis,  hyper- 
acidity, and  dyspeptic  symptoms. 

In  biliary  colic  the  pain  is  usually  to  the  right  of  the  median 
line,  radiating  to  the  right  and  to  the  right  scapula  and  shooting 
toward  the  right  ilium.  Chills,  fever,  and  jaundice  are  also 
present. 

In  renal  colic  the  pain  begins  at  the  kidney  and  radiates  along 
the  corresponding  ureter.     The  pain  is  mostly  posterior. 

Abdominal  colic  is  attended  by  gaseous  distention  and  is  cen- 
tered lower  down  in  the  abdomen. 

Angina  pectoris  is  characterized  by  pain,  which  radiates  from 
the  heart  down  the  left  arm  and  accompanied  by  a  sense  of  con- 
striction of  the  thorax,  and  a  strong  fear  of  impending  death; 
in  angina  pectoris  the  patient  sits  upright,  in  gastralgia  he 
usually  bends  forward  or  lies  down. 

The  gastric  crises  of  locomotor  ataxia  may  be  recognized  by  the 
concomitant  signs,  the  characteristic  gait  and  pupils,  history,  etc. 

Prognosis. — The  affection  is  not  dangerous  to  life  but  may 
persist  for  an  indefinite  period. 

,  Treatment. — A  mild  attack  may  be  relieved  by  antipyrin,  gr.  x 
(0.65  gm.),  and  the  application  of  a  hot-water  bag  over  the  stom- 
ach. Galvanism,  placing  the  anode  over  the  stomach  and  the 
cathode  near  the  spine,  is  often  beneficial.  A  mixture  of  equal 
parts  of  chloroform,  compound  tincture  of  cardamom,  aromatic 
spirits  of  ammonia  and  brandy  is  recommended;  a  teaspoon- 
ful  of  this  may  be  given  every  fifteen  or  thirty  minutes  till  relief 
is  experienced.  When  the  pain  is  very  severe  morphin,  by 
hypodermic  injection,  may  be  necessary;  but  care  must  be 
taken  to  avoid  forming  a  morphin  habit.  In  recurring  attacks 
Van  Valzah  recommends : 

I^.     Codein gr.  1/4  .016       gm. 

Ext.  cannab.  indicae  ....    gr.  i/io  .006       gm. 

Atropinse  sulphat gr.  1/200  .00032  gm, 

Aconitinae gr.  1/400  .00016  gm. 

M.     Ft.  capsul. 

S. — One  every  four  or  six  hours. 


DYSPEPSIA.  249 

During  the  interval,  the  underlying  cause  should  be  ascer- 
tained and  appropriate  treatment  instituted.  As  nerve- 
exhaustion  is  usually  the  cause,  rest,  regulated  diet,  exercise 
of  moderate  degree,  fresh  air,  nerve  tonics,  etc.,  should  be 
prescribed. 


DYSPEPSIA. 

Synonyms. — Gastric  indigestion;  heartburn;  pyrosis. 

Definition. — A  functional  disorder  of  the  stomach,  with 
deficient  secretion  in  either  the  quantity  or  quality  of  the 
gastric  juice;  characterized  by  disorders  of  the  functions  of 
digestion  and  assimilation,  and  the  presence  of  various  nervous 
symptoms. 

Causes. — Among  the  principal  etiologic  factors  may  be  men- 
tioned nervous  depression  from  worry  and  fatigue,  sedentary 
habits,  imperfect  mastication,  ingestion  of  large  quantities  of 
food,  unchanged  diet,  heredity,  neurasthenia,  hysteria,  and  the 
female  sex. 

Symptoms. — The  appetite  is  capricious,  perverted,  or  lost; 
digestion  is  difficult,  there  is  a  sense  of  distention  and  weight  in 
the  epigastrium;  and  there  is  acidity  of  the  gastric  contents 
from  decomposition  of  the  albuminoids.  Heartburn,  flatulency, 
regurgitation  of  portions  of  partly  digested  food  or  acrid  fiuid- 
water-brash  or  pyrosis,  and  pain  of  soreness  at  the  pit  of  the 
stomach  during  digestion  are  also  present.  There  is  drowsiness 
after  meals  and  insomnia  at  night.  Defective  memory,  head- 
ache, diminution  or  absence  of  mental  vigor,  flashes  of  heat, 
followed  by  more  or  less  perspiration,  and  palpitation  may  be 
manifested.  The  tongue  is  usually  broad,  flabby,  and  pale 
and  shows  marks  of  the  teeth.  The  bowels  are  constipated 
and  the  urine  is  scanty,  high-colored,  and  contains  an  excess 
of  urates  and  oxalates;  in  the  nervous  type,  it  is  pale,  of  low 
specific  gravity,  and  contains  phosphates. 

Varieties  of  Dyspepsia. — There  are  many  varieties  of  dyspep- 
sia described,  and  the  following  table  (from  Wheeler  and  Jack) 


250 


DYSPEPSIA. 


shows  the  principal  points  of  the  chief  forms.      The  types  some- 
times overlap ;  hence  the  table  must  be  taken  as  a  guide  only : 


Atonic  dyspepsia. 
(Gastric  insuffi- 
ciency.) 


Acid  dyspepsia. 
(Gastric  irritation.) 


Nervous     dyspepsia. 


Immediate  cause. 


Want  of  functional 
power,  both  as  re- 
gards gastric  secre- 
tion and  move- 
ments. Hence 
often  secondary  to 
constitutional  dis- 


Usually  primary, 
but  may  follow 
other  diseases.  De- 
pendent on  errors 
of  diet,  drink,  etc. 


Mental  strain  from 
worry,  overstudy, 
hysteria,  neuras- 
thenia, etc. 


Pain,  vomiting,  etc. 


Eructations. 


Examination  of  gastric 
contents. 


Tongue. 


Fullness  and  oppres- 
sion in  chest  after 
meals;  vomiting 
absent. 


Eructations  not 
frequent,  but  flat- 
ulence  very 
marked.  Often 
some  dilatation 
of  stomach. 

Deficiency  of  HCl. 
Excess  of  lactic 
acid. 


Broad,  flabby,  pa- 
pillae raised,  furred; 
at  the  back,  and! 
tremulous. 


ine 

Normal      or     high- 

colored    from 

urates. 

ecial  points 

...     Most      common 

amongst  young 
women.  Apt  to 
persist. 


Dull  pain  some 
time  after  food;: 
nausea  and  vomit- i 
ing.  : 


Flatulence  common. 


Excess  of  HCl,  and 
sometimes  of  lactic 
and  butyric  acids. 


Broad  also,  but 
usually  coated 
with  a  thick  yel- 
lowish fur.  Saliva 
increased  at  first, 
mouth     afterward 


dry. 


Often  severe  gas- 
tralgia,  relieved  by 
food ;  but  may 
simulate  pain  of 
ulcer.  Vomiting 
not  common. 

Eructations  of  gas 
or  fluid  very 
marked,  and  flatu- 
lence extreme. 
Hiccough  very 
frequent. 

Secretion  of  HCl 
variable ;  often  in 
excess,  at  other 
times  deficient. 

Is  usually  clean, 
raw-beef-like  in 
character,  pointed 
tip,  firm,  not 
flabby. 


High-colored  de-  Pale  deposit  of 
posits,  "gravel,"  amorphous  phos- 
and  oxalates.  phates. 


Most  common 
amongst  middle- 
aged  people  of 
generous  build. 
Paroxysmal  in 
character,  mi- 
graine and  mental 
depression  marked 
during  the  attack. 


Most  common  in 
neurasthenics,  or 
those  subject  to 
nervous  altera- 
tions.  Little  in- 
fluenced by  treat- 
ment, the  predis- 
position remain- 
ing. Insomnia  a 
prominent  symp- 
tom, and  other 
nervous  disturb- 
ances common. 


DYSPEPSIA.  251 

Prognosis. — With  the  institution  of  proper  treatment  the 
outlook  is  favorable,  otherwise  the  duration  is  indefinite. 

Treatment. — As  dyspepsia  is  a  symptom,  the  probable  cause 
should  be  sought,  and  if  possible  removed.  The  patient's 
cooperation  is  very  desirable;  and  it  should  be  remembered 
that  each  patient  has  his  own  peculiarities.  Regulation  of  the 
diet  is  of  great  importance ;  but  the  use  of  rigid  diet  charts  will 
often  result  in  failure.  Saccharine,  starchy,  or  fatty  articles  of 
food  should  be  interdicted.  Mastication  should  be  slow  and  com- 
plete and  only  small  quantities  of  food  should  be  taken  at  a  time. 
Underdone  meats,  "Salisbury  steaks,"  eggs,  fish,  oysters,  and 
green  vegetables  with  stale  or  brown  bread  are  advised.  Stimu- 
lants should  not  be  taken  with  the  meals,  and  only  small  quanti- 
ties of  liquids  should  be  allowed.  Rest  of  a  half  to  an  hour's 
duration  after  meals  is  of  benefit.  General  physical  and  mental 
rest  is  indicated  in  the  nervous  type. 

The  medicinal  treatment  embraces  a  great  number  of  remedies, 
■  but  care  must  be  taken  not  to  make  a  drug  store  of  the  patient's 
stomach.  As  aids  to  digestion,  the  following  formulas  may  be 
prescribed : 


I^.      Pepsini  pur 5 j  4 .  gm. 

Acid,  hydrochlorici  dil .  .    f  oiv  15.  c.c. 

Glycerini f  3iv.  15  .  c.c. 

Aq.  lauro-cerasi f  §ij  60.  c.c. 

M.  S. — One  teaspoonful,  diluted,  with  meals. 

I^.     Papoid  (pur.) gr.  xxx  2 .  gm. 

Sodii  bicarb gr-  Ix  4 .  gm. 

Pulv.  zingib gr-  v  .3  gm. 

M.     Ft.  capsul.  or  pil.  No.  xx. 
S. — One  at  mealtime  and  bedtime. 


To  stimulate  peristalsis,  nux  vomica,  gentian,  or  cinchona 
may  be  used,  and  for  the  acidity,  alkalies,  particularly  bicar- 
bonate of  sodium,  may  be  given.     In  atonic  cases,  Hare  advises: 


252  DYSPEPSIA. 

I^.     Extract!  nucis  vomicae.  .    gr.  iv  0.25  gm. 

Extract!  quassiae gr.  xx  i  .30  gm. 

Quininae  sulphatis gr-  xl  2  .  60  gm. 

M.  et  divide  in  pil.  xx. 

S. — One  three  times  a  day  after  meals. 

Or— 

I^.     Extracti  chiratse gr.  xl  2  .  60  gm. 

Extracti  gentianae gr.  xl  2  .  60  gm. 

Oleoresinae  capsici ttlv  0.32  gm. 

M.  et  divide  in  pil.  xx. 
S. — One  after  each  meal. 

Purified  animal  charcoal,  gr.  x  to  xx  (0.65  to  1.3  gm.),  or  one  of 
the  carminatives  will  relieve  flatulency.  Pyrosis  may  be 
benefited  by  the  administration  of  bismuth  subnitrate,  gr.  xx 
(1.3  gm.),  and  aromatic  powder,  gr.  v  (0,32  gm.).  Vomiting 
may  be  overcome  by  the  use  of  sodium  or  strontium  bromid,  gr. 
V  (0.3  gm.),  carbolic  acid,  gr.  1/6  to  1/4  (o.oii  to  0.016  gm.), 
or  chloral  hydrate,  gr.  x  to  xv  (0.65  to  i  gm.).  Irrigation  of 
the  stomach,  or  the  drinking  of  1/2  to  i  pint  of  hot  water  an 
hour  before  meals  is  very  beneficial.  In  anemic  cases,  iron, 
quinin,  strychnin,  and  arsenic  will  be  required.  For  constipa- 
tion Hunyadi  water,  resin  of  podophyllum,  or  the  following 
may  be  used: 

I^.      Sodii  bicarbonatis 5ij  8.  gm. 

Tinct.  nucis  vomicae  ....        f  3iv  15.  c.c. 

Tinct.  capsici f5j  4.  c.c. 

Tinct.  rhei fgiss  45.  c.c. 

Inf.  gentian,  comp.q.  s.  ad     f5vj        ad     180.  c.c. 
M.  S. — Half  tablespoonful  after  meals,  in  water. 

I^.     Fid.  ext.  cascarae  sagradae  f5  j  30.  c.c. 

Tinct.  nucis  vomicae  .  .  .  .    f  §  ss  15  .  c.c. 

Syr.  zingib f  B  ss  15.  c.c. 

Inf.  sarsaparillae.  .q.  s.  ad  fS  iij  ad  90.  c.c. 

M.  S. — Teaspoonful  three  times  daily,  diluted. 


INTESTINAL  INDIGESTION.  253 

DISEASES  OF  THE   INTESTINES. 

INTESTINAL  INDIGESTION. 

Definition. — Intestinal  indigestion  or  dyspepsia  is  a  functional 
derangement  due  to  defects  in  the  various  intestinal  secretions, 
or  deficient  peristalsis,  or  both,  resulting  in  more  or  less  complete 
decomposition  of  the  chyme ;  characterized  by  abdominal  pain 
and  distention,  tympanites  developing  some  hours  after  meals, 
emaciation,  anemia  and  various  nervous  symptoms. 

Causes. — It  may  be  inherited  or  it  may  be  due  to  imperfect 
diet,  over-eating,  irregular  meals,  deficient  exercise,  worry  and 
mental  fatigue,  immoderate  use  of  tobacco,  or  stimulants, 
diseases  of  the  stomach,  intestinal  tract,  liver,  or  pancreas,  or 
malaria. 

Symptoms. — The  affection  may  be  acute  or  chronic. 

The  acute  form  is  usually  the  result  of  an  irritant  in  the  duo- 
denum and  is  attended  by  rapidly  developed  pain,  flatulency, 
borborygmi,  slight  fever,  coated  tongue,  loss  of  appetite,  head- 
ache, and  diarrhea.  In  sudden  attacks,  the  accumulated  gases 
often  cause  paroxysms  of  colic.  Severe  attacks  are  associated 
with  jaundice,  light-colored  stools,  and  high-colored  urine, 
indicating  hepatic  disturbance.  In  such  cases,  the  onset  is 
a,ccompanied  by  malaise,  chilliness,  fever,  100°  to  102°  F., 
increased  pulse,  headache  with  or  without  vomiting,  coated 
tongue,  abdominal  pains  increased  on  pressure,  tympanites, 
cramps  in  the  legs,  and  diarrhea.  The  stools  are  at  first  soft 
and  normal  with  fecal  odor  and  color  becoming  later  frothy, 
watery,  of  a  peculiar  odor,  and  made  up  of  mucus  and  undigested 
food.  Their  reaction  is  alkaline,  and  the  microscope  shows 
epithelial,  round,  and  blood-cells,  Charcot's  crystals,  crystals 
of  the  oxalate  of  calcium,  calcium  phosphate,  etc. 

The  chronic  variety  follows  varying  grades  of  decomposition  in 
the  pasty,  digested  food  after  it  has  left  the  stomach.  It  is 
attended  by  pain,  two  to  four  to  six  hours  after  meals,  with 
tenderness  and  distention  in  the  upper  abdomen,  tympanites. 


2  54  INTESTINAL    INDIGESTION. 

borborygmi,  dyspnea,  and  constipation.  Anemia,  emaciation, 
functional  derangement  of  the  liver,  and  marked  nervous 
phenomena  develop  as  the  affection  progresses.  The  skin  is 
harsh  and  dry,  and  the  urine  is  high-colored,  of  increased  specific 
gravity,  and  acid  in  reaction,  and  on  cooling  deposits  lithates, 
uric  acid,  and  oxalate  of  lime  crystals. 

Diagnosis. — The  late  appearance  of  the  symptoms  after  inges- 
tion of  the  meals  is  the  main  feature  in  distinguishing  intestinal 
indigestion  from  gastric  indigestion.  Usually  they  exist  more 
or  less  combined. 

Treatment. — In  the  acute  variety,  opium  should  be  given  and 
heat  applied  to  the  abdomen  to  relieve  the  distress,  and  a  cathar- 
tic, preferably  calomel,  followed  by  a  saline,  administered  to 
expel  the  irritant. 

I^.      Hydrarg.  chlorid.  mit .  .  .  gr.  1/3  .02  gm. 

Sodii  bicarb gr.  ij  .  13  gm. 

Pulv.  ipecac gr.  1/6  .01  gm. 

Sacch.  lact gr.  iij  .  2     gm. 

M.     Ft.  charta. 

S. — One  every  two  hours  until  six  have  been  taken. 

After  which  stimulate  the  gastrointestinal  canal  with : 

I^.      Tinct.  nucis  vomicae  ....    f  oiv  15.  c.c. 

Acid,  hydrochlorici  dil  .  .    f  oiv  15.  c.c. 

Tinct.  card,  comp f  oiv  15.  c.c. 

Ess.  pepsin q.  s.  ad  f  oiij  ad  90.  c.c. 

M.  S. — Teaspoonful  every  three  hours,  diluted. 

For  the  more  severe  variety  of  intestinal  indigestion  (or 
catarrh) ,  wash  out  large  bowel  with : 

I^.      Magnesii  sulphat oj  30.  gm. 

Glycerini f oj  30.  c.c. 

Aquae  bul. f  oiv  120 .  c.c. 

M.  S.* — Slowly  inject  into  bowel  from  a  fountain  syringe. 


INTESTINAJ.    IMJlOESTION.  255 

Internally  either  of  the  following  excellent  combinations: 

I).      Napthalini gr.  xxx  2 .       gm. 

Bismuth,  salicylat gr.  Ixxx  6.       gm. 

Acid,  carbolici gr.  iv  .26  gm. 

Glycerin! f  5j  30  •        c.c. 

Aq.  chloroformi f  5iij  90  ■        c.c. 

M.  S. — Two  teaspoonfuls  every  two  or  three  hours,  diluted. 

Or— 

T^.      Sodii  phosphat oj  30.  gm. 

Acid,  phosph.  dil f  3iv  15.  c.c. 

Syr.  limonis f  oj  30.  c.c. 

Aq.  chloroformi f  5iij  90.  c.c. 

Aq.  menth.  pip f  5iiiss  100.  c.c. 

M.  S. — One  tablespoonful  after  meals,  well  diluted. 

Chronic  cases  require  the  administration  of  laxatives  such  as 
Bedford,  Friedrichshall,  Pullna,  or  Hunyadi  Janos  waters,  resin 
of  podophyllum,  or  fluidextract  of  cascara  sagrada  and  intes- 
tinal digestants.  Purified  oxgall,  gr.  i  to  iii  (0.065  to  0.2  gm.) 
after  meals,  or  the  following  may  be  employed: 

I^.     Papoid gr.  j  to  ij     .  065  to  .  13  gm. 

Naphtalini gr.  j  .065  gm. 

Ext.  nucis  vomicae.  ..  .    gr.  1/3         .022  gm. 

M.     Ft.  pil. 
S. — One  such  to  be  taken  every  four  or  six  hours. 

Excellent  results  follow  the  use  of  the  following  pill: 

I^.      Sodii  arsenat gr.  1/20  .003  gm. 

Strychninae  sulphat gr.  1/32  .002  gm. 

Pepsinae  pur g^-  ij  -13     g'^- 

M.  S. — After  each  meal. 

The  diet  should  be  restricted  in  amount  and  confined  almost 
entirely  to  articles  which  are  readily  digested  in  the  stomach, 
such  as  beef,  eggs,  and  milk. 


256  INTESTINAL   COLIC. 

INTESTINAL  COLIC. 

Synonyms. — Enteralgia;  tormina;  gripes. 

Definition. — A  spasmodic  contraction  of  the  muscular  layer 
of  the  intestinal  tube;  characterized  by  acute  paroxysmal  pain 
near  the  umbilicus,  relieved  by  pressure,  and  associated  with 
feeble  cardiac  action. 

Causes. — Intestinal  colic  may  be  due  to  constipation,  the 
presence  of  indigestible  food,  or  an  abnormal  quantity  of  bile 
in  the  intestinal  tract,  structural  lesions  of  the  intestinal  wall, 
lead-poisoning,  syphilis,'  gout,  rheumatism,  locomotor  ataxia, 
malaria,  hysteria,  or  reflex  causes. 

Symptoms. — Paroxysmal  pain  of  a  tearing,  cutting,  pressing, 
twisting,  pinching,  or  bearing-down  character  centering  around 
the  umbilicus  is  the  most  prominent  symptom.  The  abdomen 
is  tense  and  pressure  upon  it  relieves  the  pain.  In  severe  attacks 
the  surface  is  cold;  the  features  are  pinched;  the  pulse  is  small 
and  hard;  and  there  may  be  nausea,  vomiting,  and  tenesmus. 
Constipation  is  usually  present.  The  duration  is  from  a  few 
minutes  to  several  hours,  often  with  intermissions.  A  discharge 
of  flatus  is  the  usual  termination. 

Diagnosis. — Gastralgia  differs  from  colic,  in  the  pain  being  in 
the  epigastric  region  and  associated  with  disorders  of  digestion. 

In  heptic  colic,  or  the  pain  due  to  the  passage  of  gallstones, 
the  pain  is  in  the  hepatic  region,  radiates  to  the  right  shoulder, 
is  attended  with  soreness  over  the  gall-bladder,  and  retching 
and  vomiting,  followed  by  jaundice  and  the  presence  of  bile  in 
the  urine. 

In  nephritic  colic,  the  pain  follows  the  course  of  one  or  both 
ureters,  shooting  to  loins  and  thigh,  with  retraction  of  the 
testicle  of  the  affected  side,   strangury,   and  bloody  urine. 

In  uterine  colic,  the  pain  is  in  the  pelvis,  and  associated  with 
menstrual  disorders,  in  fact,  a  dysmenorrhea. 

In  ovarian  colic  or  neuralgia,  there  is  pain  on  pressure  over 
the  ovaries,  with  hysteric  phenomena. 

Inflaminatory  disorders  of  the  abdomen  differ  from  colic  by 
the  presence  of  fever  and  tenderness  on  pressure. 


CONSTIPATION.  257 

Lead  colic  is  always  preceded  by  symptoms  of  lead-poison- 
ing: slate-colored  skin,  dark  gums  showing  a  blue  line,  heavy 
breath,  with  sweetish  metallic  taste,  obstinate  constipation, 
impaired  appetite,  slow  pulse,  and  contracted  abdominal  walls. 

Appendicitis  may  be  distinguished  by  the  localized  pain  and 
tenderness  in  the  right  iliac  fossa,  induration,  and  rigidity 
of  the  right  rectus  abdominis  muscle. 

Prognosis. — Favorable. 

Treatment. — The  pain  should  be  relieved  by  turpentine  stupes 
over  the  abdomen,  carminatives,  and  the  hypodermic  injection 
of  morphin  sulphate,  gr.  1/6  to  1/3  fo.oii  to  0.22  gm.).  In 
all  cases,  blue  mass,  gr.  v  to  x  (0.3  too.6gm.),  or  calomel,  gr.  1/2 
(0.03  gm.),  every  half  hour  until  4  or  5  grains  have  been  taken, 
should  be  administered  and  followed  by  a  saline  cathartic. 
In  the  interval,  the  cause  should  be  ascertained  and  removed. 

In  lead  colic,  morphin,  castor  oil,  or  sulphate  of  magnesia, 
potassium  iodid,  syrup  of  hydriodic  acid,  and  olive  oil  are 
indicated. 

CONSTIPATION. 

Synonyms. — Costiveness;  intestinal  torpor. 

Definition. — A  functional  inactivity  of  the  intestinal  canal, 
either  due  to  atony  of  the  muscular  coat,  causing  lessened 
peristalsis,  or  to  deficiency  of  intestinal  and  biliary  secretion; 
characterized  by  a  change  in  the  character,  frequency,  and 
quantity   of  the   stools. 

Varieties. — There  are,  thus,  three  types  of  constipation:  (i) 
Insufficient  frequency  of  defecation;  (2)  insufficient  quantity; 
and  (3)  defecation  of  abnormally  dry  and  hard  masses. 

Causes. — Diseases  of  the  digestive  tract,  fevers,  diseases  that 
lessen  intestinal  secretions,  affections  that  diminish  peristalsis, 
sedentary  habits,  neglect,  painful  defecation,  improper  food, 
change  of  diet  or  habits,  malaria,  lead-poisoning,  atony  of  the 
intestinal  and  abdominal  walls,  strictures,  displaced  organs, 
and  foreign  bodies  are  the  common  causes. 

Symptoms. — One  stool  in  twenty-four  hours  may  be  taken  as 
an  indication  of  the  normal  state  as  regards  the  intestinal 
17 


258  CONSTIPATION. 

tract;  less  than  this  constitutes  constipation,  although  it  may 
be  unattended  with  any  discomfort,  for  a  considerable  period. 
The  change  in  number,  quantity,  and  consistency  gives  rise 
eventually  to  straining,  distress,  tenesmus,  and  irritation  of 
the  rectum.  These  are  followed  by  dyspeptic  symptoms, 
anorexia,  headache,  mental  torpor,  vertigo,  palpitation,  and 
often  abdominal  distention. 

Prognosis. — The  outlook  is  favorable  but  the  course  is  likely 
to  be  indefinite.  Hemorrhoids,  varicocele,  impaction,  anal 
fissure,  ulceration,  and  similar  conditions  may  occur  as  sequels. 

Treatment. — In  all  cases  a  careful  examination  should  be 
made  to  ascertain  the  cause,  which  should  be  promptly  removed. 
A  large  portion  of  the  treatment  in  ordinary  cases  rests  with 
the  patient. 

1.  The  patient  must  have  a  regular  hour  each  day  for  going 
to  stool,  and  must  remain  a  sufficient  time  to  permit  a  thorough 
evacuation  of  the  bowels,  until  habit  of  daily  stools  is  formed, 
taking  (if  necessary)  a  warm  water  injection. 

2.  The  diet  must  be  carefully  regulated,  as  concentrated 
foods  increase  the  costive  habit,  so  that  those  predisposed 
should  eat  bulky  foods,  much  vegetables  and  fruits.  Bran 
bread,  gluten  bread,  water-drinking,  cornmeal,  and  oatmeal 
should  be  advised. 

3.  Purgative  mineral  waters,  such  as  Saratoga,  Bedford, 
Apenta,  Carlsbad,  Friedrichshall,  and  Hunyadi  Janos  should 
be  cautiously  employed.  Purgation  should  be  avoided  if 
possible ;  a  mild  laxative  may  be  used  frequently,  even  habitu- 
ally if  necessary.  An  old  favorite  is  the  following  excellent 
combination : 

I^.     Aloin gr.  1/4  .016  gm. 

Strychninas  sulphatis .  .  .  gr.  1/60  o.ooi  gm. 

Extr.  belladonnas gr.  1/16  .  .004  gm. 

Extr.  cascaras  sagradae  .  .  gr.  ss  .032  gm. 
M.  S. — One  such  pill  t.  i.  d. 

Epsom  salt  or  Rochelle  salt  is  a  very  efficient  drug  in  this 
condition.     Aloin,  gr.   1/8  to  1/4    (0.008   to   0.016  gm.),   after 


DIARRHEA.  259 

meals,   or  glycerin   in   enema  or  suppository  may  also  be  em- 
ployed to  combat  the  constipation.      The  tone  of  the  intestinal 
wall  may  be  restored  by  electricity  or  kneading  of  the  abdomi- 
nal walls,  systematic  exercise,  cold  bathing,  and  rnassage. 
4.      The    administration   of   one   of   the   following   formulas: 

I^.      Ext.  nucis  vomicae gr.  1/4  .016  gm. 

Ext.  belladonnas  (alco.)  .  gr.  1/4  .016  gm. 

Ext.  aloes gr.  ss  .032  gm. 

Pulv.  rhei gr-  j  065  gm. 

Olei  cajuputi rr\j  .06     c.c. 

M.  S. — In  pill,  at  bedtime;  and  after  a  week,  every  second 
or  third  night. 

r^.      Resinse  podophyl., 
Ext.  physostig., 
Ext.  belladonnas  (alco.), 

Aloini aa   gr.  i  1 4.  aa   .016  gm. 

M.  S. — In  pill,  every  night,  or  second  or  third  night. 

I^.     Fid.  ext.  cascarae  sagradse    n\xx  1.3  c.c. 

Glycerini rr^xx  1  .  3  c.c. 

vSvr.  sarsaparill^ nxxx  i  .3  c.c. 

M.  S. — To  be  taken  one  hour  after  meals,  or  once  a  day, 
as  indicated. 

Treatment  of  Constipation  of  Infants. — Drinking  of  a  little 
water  or  barley  water,  or  oatmeal  water,  will  often  overcome  the 
difficulty.  Small  suppositories  of  glycerin  or  soap  may  be  used 
or  an  injection  of  cold  water  may  be  tried,  and,  if  necessary, 
repeated.  For  older  children,  castor  oil  or  effervescent  magne- 
sium sulphate  will  be  found  suitable ;  but  fruit  should  be  tried 
first.      Drugs  should  not  be  used  if  any  other  method  will  suffice. 

DIARRHEA. 

Synonyms. — Enterorrhea;  alvine  flux;  purging. 

Definition. — Frequent  loose  alvine  evacuations,  without 
tenesmus;  due  to  functional  or  organic  derangement  of  the 
small  intestines,  produced  by  causes  acting  either  locally  or 
constitutionally. 


26o  DIARRHEA. 

Causes.-— Among  the  local  causes  may  be  mentioned  indiges- 
tion, indigestible  food,  impure  food  and  water,  irritating  matters 
or  secretions  poured  into  the  bowels,  intestinal  inflammation, 
and  entozoa.  The  general  causes  include  atmospheric  changes, 
sudden  mental  shock,  purgatives,  certain  infectious  fevers,  and 
cachectic  conditions  such  as  attend  tuberculosis,  pyemia, 
Bright's  disease,  cancer,  diabetes,  etc. 

Symptoms. — Diarrhea  may  be  acute  or  chronic  and  is  mani- 
fested chiefly  by  an  alteration  in  the  nufnber  and  character  of 
the  stools.  Mucous  stools  are  those  in  which  there  are  great 
quantities  of  mucus,  indicating  inflammation  of  the  lower 
bowel.  Lienteric  stools  contain  much  undigested  food  and 
point  to  inflammation  of  the  stomach  and  upper  bowel. 
Watery  or  serous  stools  occur  in  nervous  and  colliquative  diar- 
rheas, enteritis,  cholera,  and  similar  affections.  Green  stools 
may  be  due  to  an  excess  of  bile,  bacterial  growth,  or  marked 
alkalinity  of  the  digestive  tract.  Fatty  stools  are  produced  by 
the  ingestion  of  large  quantities  of  fatty  foods,  pancreatic  dis- 
eases, and  the  absence  of  bile.  Purulent  stools  arise  from  ulcera- 
tion along  the  intestinal  canal  or  the  rupture  of  adjacent 
abscesses  into  the  bowel.  Black  stools  may  be  due  to  the 
presence  of  blood  from  hemorrhages  high  up  in  digestive  tract, 
bismuth,  charcoal,  tannate  of  iron,  etc.  Red  stools  may  result 
from  the  presence  of  fresh  blood  or  the  administration  of 
diarrhea  mixtures  containing  hematoxylon.  Bloody  stools  or 
melena  follow  hemorrhage  from  any  portion  of  the  digestive 
tract  and  result  from  inflammation,  ulceration,  traumatism, 
infectious  fevers,  chronic  heart,  liver,  or  kidney  disease,  infarc- 
tion, hemorrhoids,  anal  fissure  and  fistula,  rupture  of  an  aneur- 
ysm, scurvy,  purpura,  and  vicarious  menstruation. 

Acute  diarrhea  presents  itself  in  several  forms.  In  the  fecu- 
lent form  which  results  from  indiscretions  in  diet,  intestinal 
parasites,  and  indigestion,  the  patient  experiences  within  a  few 
hours  after  meals  colicky  pains,  nausea,  flatulency,  and  a  desire 
for  stool.  The  tongue  may  be  coated.  Purging  relieves  the 
pain.  The  stools  are  composed  of  a  brown  fluid  and  feces,  and 
are  very  offensive.     Their  color  becomes  lighter  after  four  or 


DIARRHEA.  26 1 

five  evacuations.  The  duration  is  seldom  more  than  two  or 
three  days.  In  the  lienteric  variety,  the  food  passes  through 
unaltered  or  very  slightly  digested.  The  stools  are  frequent 
and  in  addition  to  the  undigested  food,  there  is  bile,  mucus, 
and  serum.  Emaciation  is  common.  In  the  bilious  form, 
which  is  due  to  excess  of  bile,  griping  pains  in  the  abdomen  and 
scalding  sensations  at  the  anus  are  present,  and  the  stools  are 
green  or  yellow. 

Chronic  diarrhea  results  from  the  persistence  of  acute  diarrhea 
or  constitutional  affections.  The  stools  continue  frequent,  but 
are  paler  in  color.  Emaciation,  anemia,  dyspepsia,  etc., 
accompany  this  affection. 

Prognosis. — As  diarrhea  is  only  a  symptom  its  prognosis  de- 
pends upon  the  underlying  condition.  In  the  feculent  and 
bilious  forms  it  is  favorable,  but  in  the  lienteric  and  chronic 
forms,  when  emaciation  begins,  it  assumes  an  unfavorable 
character. 

,  Treatm.ent. — Acttte  Diarrhea.  If  the  tongue  is  heavily  coated, 
the  breath  fetid,  and  the  stools  not  excessive  in  number,  it  is 
well  to  clear  the  intestinal  canal  with  a  laxative  such  as  castor 
oil  or  a  saline.  For  children  between  one  and  two  years  of 
age: 

I^.     Pulv.  ipecac gf-  ss  .032  gm. 

Pulv.  rhei gr.  1/4  to  1/3  .016  to  .022  gm. 

Sodii  bicarb gr.  ss  to  ij         .  032  to  .13     gm. 

M.   S. — Every  four  hours  until  the  character  of  the  stools 
changes. 

As  a  rule,  however,  the  stools  have  become  so  frequent  when 
advice  is  sought  that  the  time  for  laxatives  has  passed,  and  some 
one  of  the  following  combinations  is  indicated: 

I^.      Salol gr.  XX  to  xxx     1.3  to  2  .  gm. 

Bismuth  subnitrat.     oj  4.  gm. 

Sacch.  lac oj  4.  gm. 

M.     Ft.  chart.  No.  x. 

S. — One  every  two  or  three  hours,  reducing  the  dose  for 
children. 


262 


DIARRHEA. 


Or- 


I^.      Bismuthi  salicylat gr.  xxx 

Morphinae  sulphat gr.  j 

M.     Ft.  chart.  No.  vj. 

S. — One  every  three  hours. 


2.  gm. 

.065  gm. 


Or  the  following  modification  of  Squibb's  "  diarrhea  mixture"  : 

I^.      Tinct.  opii  deodorat  ....    f  oiv  15.  c.c. 

Tinct.  camphorae f  5iv     '  15.  c.c. 

Tinct. capsici f  oij  8  .  c.c. 

Chloroformi f  5iss  '            6  .  c.c. 

Spts.  vini  gallici f  oj  30.  c.c. 

Vini  pepsini q.  s.  ad  f  5  iij  ad  90.  c.c. 

M.  S. — One  teaspoonful,  p.  r.  n. 

Or  the  following: 

I}.      Tinct.  opii  deodorat  ....    f  oiv  15.  c.c. 

Spts.  chloroformi f  5ij  8.  c.c. 

Acid,  sulphuric,  dil f  §j  30.  c.c. 

Vini  pepsini q.  s.  ad  f  5iij  ad  90.  c.c. 

M.  S. — One  teaspoonful  in  water  after  each  stool. 

For  the  bilious  form : 

I^.      Hydrarg.  chlorid.  mitis  .    gr.  1/8  .008  gm. 

Sodii  bicarb gi^-  ij  -13     gm- 

Pulv.  opii gr.  1/4  .016  gm. 

M.   S. — Every  two  or  three  hours  until  eight  powders  are 

used,  followed  by  large  doses  of  bismuth  and  pepsin. 


In  all  acute  forms,  restricted  and  regulated  diet  are  impera- 
tive, pure  milk  with  lime-water  being  the  most  suitable. 

In  adults,  an  opium  suppository  often  checks  a  flux  that  is 
uninfluenced  by  opium  internally. 

Irrigation  of  the  colon  with  a  warm  salt  solution  is  often 
beneficial. 

Chronic  Diarrhea.  Bismuth,  gr.  xxx  to  xl  (2  to  2.6  gm.),  in 
milk  every  four  hours;  Hope's  camphor  mixture,  f  §j  (30  c.c). 


CATARRHAL    ENTERITIS.  263 

every  four  hours;  or  copper  sulphate,  gr.  1/12  (0.005  gm.), 
extract  of  opium,  gr.  1/12  (0.005  gm.),  every  four  hours;  or 
silver  nitrate,  gr.  1/6  (0.0 1  gm.),  extract  of  opium,  gr.  1/5 
(o.oii  gm.),  every  five  hours;  may  all  be  used  with  more  or  less 
success;  when  dry  tongue  and  great  flatulency  are  present,  use: 

I^.      01.  terebinthinae f  5j  4-  c.c. 

01.  amygdal.  express.  ..  .    f5ss  15.  c.c. 

Tinct.  opii f  5ij  8  .  c.c. 

Mucil.  acaciae f  oiv  1 5  .  c.c. 

Aq.  lauro-cerasi f  oss  15.  c.c. 

M.  S. — One  teaspoonful  every  three  or  four  hours,  diluted. 

The  diet  should  be  nutritious  in  character,  and  stimulants  in 
moderation  are  indicated.  Activity  of  the  skin  and  kidneys 
should  be  encouraged. 

All  varieties  of  intestinal  catarrh  or  diarrhea  are  benefited 
by  a  few  days'  rest  in  bed  and  daily  hot  baths. 

CATARRHAL  ENTERITIS. 

Synonyms. — Intestinal  catarrh;  acute  diarrhea;  ileocolitis; 
inflammation  of  the  bowels. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  small  intestines;  characterized  by  fever,  pain, 
tenderness,  and  looseness  of  the  bowels.  When  the  catarrh  is 
limited  to  the  duodenum  it  is  termed  duodenitis,  and  is  attended 
by  slight  jaundice. 

Causes. — In  some  cases,  a  specific  virus  seems  to  be  the  etio- 
logic  factor.  Ptomain  poisoning,  such  as  follows  the  ingestion 
of  decomposed  food  and  milk,  improper  and  indigestible  food, 
overeating,  and  excessive  drinking,  summer  season,  exposure 
to  cold,  and  wet  while  perspiring,  irritants  such  as  foreign  bodies 
in  the  intestinal  tract,  childhood,  imperfect  hygiene,  and  in- 
organic poisons  may  be  mentioned  as  the  most  common  causes. 

Pathologic  Anatomy. — There  first  ensues  hyperemia  of  the 
mucous  membrane  and  intestinal  glands,  manifested  by  redness, 
swelling,  and  edema;  this  is  followed  by  increased  secretion,  and 


264  CATARRHAL    ENTERITIS. 

an  overgrowth  and  desquamation  of  the  epithelium,  together 
with  a  copious  generation  of  young  cells.  As  a  result  of  the 
hyperemia,  rupture  of  the  capillaries  and  extravasation  of  blood 
often  occur. 

The  swollen  glands  show  a  strong  tendency  to  ulcerate.  This 
catarrhal  process  may  involve  the  entire  tube  or  be  limited  to 
portions  of  it.  If  the  catarrhal  changes  extend  to  the  ileum, 
the  solitary  and  Peyer's  glands  show  swellings  that  might  be 
mistaken  for  the  changes  of  typhoid  fever. 

Symptoms. — The  acute  form  begins  with  languor,  chilliness, 
fever  102°  to  103°  F.,  anorexia,  colicky  pains,  and  localized 
abdominal  tenderness.  Nausea  and  vomiting  often  occur. 
The  bowels  are  at  first  constipated,  but  later  diarrhea  super- 
venes. The  stools  at  first  have  ordinary  fecal  contents  and  are 
very  offensive,  later  they  are  less  offensive  and  contain  but 
little  fecal  matter;  are  yellow  or  greenish  yellow  in  color,  and 
mixed  with  undigested  food.  When  very  numerous  they  be- 
come thin  and  watery,  constituting  the  3o-called  "rice-water" 
discharges.  A  peculiar  abdominal  eruption  has  been  observed 
in  severe  cases;  it  occurs  as  isolated  dark,  red  spots,  larger 
than  those  of  typhoid  fever,  disappearing  on  pressure  and  with 
the  decline  of  the  fever,  each  lesion  lasting  about  twenty-four 
hours. 

In  the  chronic  form,  in  addition  to  the  diarrhea,  emaciation 
and  anemia  are  present.  The  stools  are  thin,  watery,  and 
numerous.  The  presence  of  undigested  food  in  the  evacuations 
indicates  inflammation  of  the  small  intestine,  while  the  pres- 
ence of  considerable  mucus  points  to  involvement  of  the  large 
intestines. 

Diagnosis. — Colic  resembles  enteritis  only  in  the  character 
of  the  pain,  and  lacks  abdominal  tenderness,  diarrhea,  and  fever. 

Typhoid  fever  is  distinguished  by  its  prodromes,  temperature 
record,  eruption,  enlarged  spleen,  character  of  the  stools,  and 
the  Widal  reaction. 

Dysentery  is  characterized  by  small,  mucous  blood-stained 
discharges,  and  marked  tenesmus. 

Peritonitis  may  be  differentiated  by  its  intense  pain  and  ten- 


CATARRHAL    ENTERITIS.  265 

derness,  tympany,  marked  constitutional  reaction,  decubitus, 
and  constipation. 

Cholera  may  resemble  enteritis  when  the  attack  is  mild,  but 
a  bacteriologic  examination  of  the  stools  will  aid  in  making  the 
diagnosis. 

Prognosis. — The  prognosis  is  favorable  when  the  treatment  is 
prompt  and  appropriate.  Mild  cases  last  for  four  or  five  days, 
severe  cases  may-  continue  for  one  or  two  weeks.  In  chronic 
enteritis,  the  diarrhea  may  persist  indefinitely. 

Treatment. — The  patient  should  be  placed  in  bed  and  the  diet 
restricted  to  such  articles  as  milk,  and  lime-water,  or  mutton  or 
chicken  broths  to  which  well-boiled  rice  has  been  added.  In 
most  cases  it  is  well  to  begin  the  treatment  by  the  administra- 
tion of  some  milk  laxative  such  as  calomel,  magnesia,  or  Epsom 
salt  to  relieve  the  intestinal  tract  of  irritants.  For  adults,  the 
best  rem.edy  is  opium.  The  following  formulas  may  be  em- 
ployed : 

I^.      Ext.  opii gr.  1/4  to  1/2   .016  to  .032  gm. 

Camphorae  pulv gr-  iij  -2  gm. 

M.  S. — In  pill,  every  three  hours. 

Or— 

I^.      Tinct  opii  deodorat nxx  .6  c.c. 

Liq.  potassii  citrat foil  8.     c.c. 

M.  S. — Every  hour  until  opium  effect  is  manifested. 

The  strength  and  the  frequency  of  administration  of  either 
of  these  formulas  must  be  governed  by  the  severity  of  the  attack. 

Salol,  gr.  i  to  iii  (0.065  "to  o-2  gm.),  alone  or  combined  with 
bismuth  salicylate,  gr.  x  to  xv  (0.6  to  i  gm.),  every  three 
hours  may  also  be  used. 

If  vomiting  is  annoying,  all  other  treatment  must  be  dis- 
continued until  it  has  been  controlled,  the  following  being 
usually  efficient: 

I^.      Hydrarg.  chlorid.  mit .  .  .  gr.  1/8  .008  gm. 

Sodii  bicarbonat gr-  ij  .13     gm. 

Sacch!  lac gr-  ij  .13     g"^-  , 

M.  S. — Every  hour  or  two,  dry,  on  tongue. 


266  CROUPOUS    ENTERITIS. 

For  children:  ■    ■ 

I^.      Tinct.  opii  deodorat wy]  .06  c.c. 

Bismuth,  subnitrat gr.  v  .32  c.c. 

Mist,  cretge f5j  4.        c.c. 

M.  S. — Every  two  hours,  for  a  child  of  one  year. 

If  the  disease  shows  the  least  tendency  to  linger,  the  acid  treat- 
ment should  be  substituted,  one  of  the  best  formulas  being 
"  Hope's  Camphor  Mixture."  The  following,  which  has  been 
used  with  much  success  in  the  insane  wards  of  the  Philadelphia 
Hospital,  is  generally  satisfactory: 

I^.      Spts.  camphors f  5j  30.  c.c. 

Acid,  sulphurici  dil f  5iss  45  .  c.c. 

Tinct.  opii  deodorat  .  .  .  .    f  oj  30.  c.c. 

Tinct.  capsici f  5ss  15  .  c.c. 

Spts.  chloroformi f  oss  15.  c.c. 

Spts.  vini  gallici.  q.  s.  ad  f  ovj  ad  180.  c.c. 
M.  S.- — One  to  two  teaspoonfuls,  well  diluted,  every  three 
or  four  hours. 

In  chronic  cases,  every  attention  must  be  given  to  the  diet, 
hygiene,  clothing,  etc.  Irrigation  of  the  colon  with  silver  nitrate 
solution  (20  gr.  to  the  pint)  may  be  necessary.  Mineral  astrin- 
gents and  intestinal  antiseptics  are  of  great  value. 

Locally.  Poultices,  warm  fomentations,  such  as  turpentine 
stupe,  belladonna  ointment,  or  camphorated  oil,  are  agreeable. 

CROUPOUS  ENTERITIS. 

Synonym. — Membranous  enteritis;  pseudomembranous  en- 
teritis; diphtheritic  enteritis. 

Definition. — A  croupous  inflammation  of  the  mucous  mem- 
brane of  the  small  intestines;  characterized  by  tenderness, 
paroxysmal  pain,  moderate  fever,  and  the  formation  and  dis- 
charge at  stool  of  membranous  shreds  or  casts. 

Causes. — Adult  life,  female  sex,  neurotic  temperament, 
hysteria,  and  hypochondriasis  are  the  principal  etiologic  factors. 
A  true  croupous  enteritis  may  occur  in  poisoning  by  inorganic 


CROUPOUS    ENTERITIS.  267 

substances,  in  the  acute  infectious  diseases,  and  in  the  several 
cachexias. 

Pathologic  Anatomy. — A  subacute  inflammation  of  the  small 
intestine,  during  which  the  mucous  membrane  to  a  variable 
extent  and  depth  becomes  covered  with  a  whitish  or  grayish- 
white,  firmly  adherent,  membranous  deposit,  cemented  together 
by  a  coagulable  exudation,  and  prolonged  by  rootlets  from  the 
under  surface  into  the  intestinal  follicles. 

Symptoms. — The  affection  is  manifested  by  paroxysms,  each 
of  which  is  preceded  by  various  neurotic  symptoms.  The 
attack  begins  with  feverishness,  sense  of  soreness  and  distention  of 
the  abdomen,  colicky  pains  of  a  spasmodic  character  centering 
around  the  umbilicus,  and  abdominal  tenderness,  which  phenom- 
ena continue  for  one  or  two  days.  Diarrhea,  pain,  and  tenes- 
mus with  the  presence  of  mucus,  shreds  of  membrane  or  cylin- 
drical casts  of  the  bowel,  and  sometimes  blood  in  the  stools, 
then  become  manifest.  Relief  follows  the  discharge  of  the  casts 
although  the  generalized  abdominal  soreness  may  persist  for 
a  few  days. 

Diagnosis. — Peritonitis  and  dysentery  may  resemble  it  in  the 
early  stage,  but  the  mucous  casts  and  membranous  shreds 
which  are  passed  within  the  first  fortA^-eight  hours,  as  a  rule,  will 
serve  to  make  the  diagnosis. 

Prognosis. — Life  is  never  threatened,  but  the  disease  is  very 
obstinate  to  treatment.  The  paroxysms  occur  at  intervals  of 
a  week  or  two,  but  may  be  postponed  for  several  months. 

Treatment. — The  underlying  neurotic  condition  should  re- 
ceive the  most  careful  attention.  In  addition,  the  diet  should 
be  restricted  so  as  to  reduce  the  liquids  to  a  minimum.  The 
pain,  which  is  sometimes  excruciating,  may  require  some  prep- 
aration of  opium,  preferably  morphin,  hypodermically.  The 
administration  of  an  emulsion  of  castor  oil  and  turpentine  will 
aid  in  the  expulsion  of  the  cast  and  overcome  any  tendency 
toward  constipation.  Da  Costa  recommends  some  prepara- 
tion of  liquid  tar  for  its  alterative  effect  on  the  mucous  mem- 
brane. Alteratives  such  as  cod-liver  oil,  Fowler's  solution  of 
the  arsenite  of  potassium,   n^i   to   iii    (0.06   to   0.12  c.c),    or  bi- 


268  CHOLERA    MORBUS. 

chlorid  of  mercury,  gr.   i/6  (o.ooi  gm.),  may  serve  to  prevent 
return  of  the  paroxysms. 

CHOLERA  MORBUS. 

Synonym.s. — Sporadic  cholera;  Enghsh  cholera;  cholera  nos- 
tras; bilious  cholera. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach  and  intestines,  of.  sudden  onset;  char- 
acterized by  violent  abdominal  pains,  incessant  vomiting  and 
purging,  cold  surface,  rapid,  feeble  pulse,  spasmodic  contrac- 
tions.of  the  muscles  of  the  abdomen  and  extremities,  and  pros- 
tration. 

Causes. — Summer  and  early  autumn  season,  sudden  changes 
in  the  temperature,  and  the  presence  of  irritants  in  the  digestive 
tract  such  as  result  from  the  decomposition  of  food,  and  unripe 
fruit  and  vegetables  seem  to  be  the  most  important  factors 
in  its  production.  A  special  microorganism  resembling  the 
comma  bacillus  is  often  present  in  the  stools;  but  its  causal 
relation  has  not  been  established. 

Pathologic  Anatomy. — Except  in  cases  in  which  death  has 
occurred  within  a  few  hours,  the  gastrointestinal  mucous 
membrane  is  congested  and  denuded  of  epithelium,  and  the 
solitary  glands  and  Peyer's  patches  are  swollen  and  prominent. 
The  blood  is  thick  and  dark  in  color;  the  kidneys  are  enlarged 
and  congested;  and  in  prolonged  cases  granular  changes  appear 
in  the  muscles. 

Symptoms. — The  onset  is  sudden  and  violent  and  often  occurs 
after  midnight,  being  manifested  by  chilliness,  intense  nausea, 
vomiting,  and  purging  accompanied  by  distressing  burning 
or  tearing  abdominal  pains  or  colic.  The  vomited  matter  at 
first  consists  of  the  ordinary  contents  of  the  stomach,  but  is 
soon  replaced  by  bilious  material  and  later,  almost  pure  water. 
The  stools  are  frequent  and  often  continuous.  At  first,  ordin- 
ary feces  are  discharged,  then  liquid  whitish  or  greenish  stools, 
and  later  "  rice-water"  stools  resembling  those  of  Asiatic  cholera. 
The  surface  of  the  body  is  cold  and  covered  with  clammy  sweat, 


CHOLERA    MORBUS.  269 

and  in  severe  cases,  intense  muscular  cramps  are  present.  The 
pulse  is  small  and  feeble  and  there  is  intense  thirst.  Collapse 
may  occur.  The  patient  becomes  rapidly  weak  and  emaciated, 
the  body  appearing  to  shrink  as  in  Asiatic  cholera. 

Diagnosis. — Asiatic  cholera  may  resemble  cholera  morbus, 
but  the  history  and  the  presence  of  the  comma  bacillus  of 
Koch  in  the  stools  of  the  former  will  serve  to  make  the  diagnosis. 

Irritant  poisons,  such  as  tartar  emetic  and  elaterium,  produce 
symptoms  that  may  be  mistaken  for  cholera  morbus  and  can 
only  be  distinguished  by  the  history  and  the  detection  of  the 
cause. 

Prognosis. — The  outlook  is  favorable  in  most  cases.  The 
mortality  in  all  grades  being  about  5  per  cent.  Either 
extreme  of  life  has  an  unfavorable  influence.  Mild  cases  may 
last  only  one  or  two  days,  but  in  the  more  severe  cases  the 
affection  may  persist  for  one  or  more  weeks  and  be  followed  by 
a  tedious  convalescence. 

Treatment. — In  all  cases,  regardless  of  the  cause,  a  hypo- 
dermic injection  of  morphin  sulphate,  gr.  1/8  to  1/3  (0.008  to 
0.022  gm.),  and  atropin  sulphate,  1/120  (0.00054  gm.),  should 
be  administered,  to  be  repeated  in  a  half  hour  if  necessary. 
Liquid  preparations  of  opium  by  the  mouth  or  rectum  may 
be  occasionally  necessary  instead.  The  various  cholera  mix- 
tures (see  page  loi.)  are  useful;  so,  too,  is  Hope's  camphor 
mixture.  Chlorodyne  should  not  be  used  as  its  very  variable 
strength  and  uncertain  composition  make  it  more  dangerous 
than  useful.  The  depression  may  be  relieved  by  small  doses 
of  brandy  or  dry  champagne.  Small  pellets  of  ice  will  overcome 
the  intense  thirst  to  some  extent,  but  liquids  are  contraindicated. 

If  the  vomiting  and  purging  continue,  the  following  may  be 
made  use  of: 

I^.      Bismuth,  subnitrat gr.  xx  i  .3     gm. 

Acid  carbol. gr.  1/6  .01  gm.. 

Glycerini ^xx  i .  3     c.c. 

Aquae f  5iv  15.        c.c.  . 

M.  vS. — Every  hour,  in  water. 


270  ENTEROCOLITIS. 

If  the  vomiting  is  so  severe  that  no  opportunity  occurs  for 
the  medicament  to  come  in  contact  with  the  gastric  mucous 
membrane,  an  enema  of  chloral,  gr.  x  to  xv  (0.6  to  i  gm.), 
in  some  demulcent  with  deodorized  tincture  of  opium,  n^x  to 
XX  (0.6  to  1.2  c.c.)i  acts  often  like  magic  in  quieting  the  distress 
of  the  tortured  patient. 

For  the  muscular  cramps  Da  Costa  employs: 

I^.      Chloral oiv  15.  gm. 

Petrolat §j  32.  gm. 

M.  S. — Xo  he  rubbed  over  the  affected  muscles. 

Bartholow  suggests: 

I^.      Chloral oiij  12 .       gm. 

Morphinae  sulphat gf-iv        •  .26  gm. 

Aquae • f  5j  30.       c.c. 

M.   S. — Twenty  minims,  hypodermically,  repeated  p.  r.  n. 

Locally,  mustard  poultices,  turpentine  stupes,  and  hot  water- 
bottles  to  the  abdomen  will  be  of  benefit. 

The  after-treatment  will  consist  largely  in  regulation  of  the 
diet  and  a  course  of  tonics. 


ENTEROCOLITIS. 

Synonyms. — Inflammatory  diarrhea;  ulcerative  enterocolitis. 

Definition. — A  catarrhal  inflammation  of  the  lower  portion 
of  the  small  intestines — ileum — and  the  upper  portion  of  the 
large  intestines,  with  '  a  great  tendency  to  ulceration  of  the 
intestinal  glands  if  the  catarrh  becomes  chronic. 

Causes. — The  affection  is  most  common  in  childhood,  particu- 
larly in  the  second  summer.  Improper  and  indigestible 
food,  artificial  feeding,  summer  season,  impure  air,  uncleanli- 
ness,  and  exposure,  are  important  etiologic  factors.  It  may 
follow  any  of  the  infectious  fevers  and  disorders  of  the  intestinal 
tract  such  as  diarrhea  and  cholera  infantum.  The  Bacillus 
dysentericB  of  Shiga  is  often  present  in  the  evacuations. 


ENTEROCOLITIS.  27 1 

Pathologic  Anatomy. — The  disease  may  be  acute  or  chronic. 
In  the  acute  variety,  hyperemia,  swelling,  edema,  and  softening 
of  the  mucous  membrane  of  the  ileum  and  upper  part  of  the 
colon  are  present.  The  intestinal  follicles  are  considerably 
hyperplastic,  their  excretory  ducts  being  enlarged  and  tumid, 
and  readily  distinguished  as  grayish  or  blackish  points  in  the 
center  of  the  glands.  Peyer's  patches  present  the  same  changes 
and  a  similar  appearance,  often  seemingly  ulcerated,  but  true 
ulceration  is  absent.  In  severe  cases  there  may  be  pseudo- 
membranous formation. 

In  the  chronic  variety,  the  thickening  and  infiltration  involves 
the  submucous  and  muscular  coats  producing  induration  and 
rigidity  of  the  intestinal  walls.  Ulceration  occurs  and  extends 
through  the  entire  thickness  of  the  membrane.  "  These  ulcers, 
when  isolated,  are  from  i  to  i  i  /2  lines  in  diameter,  oval  or 
circular  in  shape,  and  either  have  sharp-cut  edges,  as 
though  the  piece  of  mucous  membrane  had  been  cut  out  with 
a  punch,  or  the  mucous  membrane  bounding  them  is  under- 
mined." The  small  ulcers  often  coalesce,  so  that  large,  ir- 
regular ulcerated  patches  of  a  grayish  white  color  are  formed, 
having  for  their  base  the  submucous  or  muscular  coats.  The 
mesenteric  glands  are  enlarged,  but  seldom,  if  ever,  undergo 
ulceration. 

Symptoms. — The  acute  form  may  develop  slowly  with  rest- 
lessness or  fretfulness,  or  suddenly  with  feverishness,  loss  of 
appetite,  thirst,  nausea,  vomiting,  abdominal  pain,  and  diarrhea. 
The  abdomen  soon  becomes  enlarged  and  tender.  The  stools 
are  characteristic,  being  small,  semifluid,  heterogeneous, 
greenish,  acid,  and  mixed  with  yellowish  particles  of  ordinary 
feces  and  undigested  casein  which  give  to  the  evacuation  the 
appearance  of  chopped  spinach.  They  vary  in  number  from 
fifteen,  to  thirty  in  twenty-four  hours.  The  temperature  is 
irregular  (102°  to  104°  F.)  and  the  pulse-rate  is  increased. 
Emaciation  is  rapid  and  pronounced. 

The  chronic  form  usually  follows  the  acute  variety,  the 
symptoms  being  less  severe,  but  persistent.  Loss  of  strength 
and  emaciation  become  extremely  pronounced.      The  temper 


272  ENTEROCOLITIS. 

is  very  irritable;  the  complexion  grows  dark,  sallow,  and  un- 
healthy, and  the  face  presents  the  "old  man"  appearance; 
the  skin  is  dry  and  harsh,  and,  in  consequence  of  the  marked 
emaciation,  either  hangs  in  folds  around  the  shrunken  limbs 
or  is  drawn  tightly  over  the  joints;  the  abdomen  is  enlarged 
and  tender,  the  stools  numbering  from  six  to  a  dozen  during 
the  day  and  night,  consisting  of  the  products  of  an  imperfect 
digestion  mixed  with  mucus,  serum,  pus,  and  oftentimes  blood, 
having  a  semifluid  consistency,  and  an  extremely  offensive 
odor.  Ulcerative  stomatitis  is  a  frequent  complication,  adding 
to  the  discomfort  of  the  patient.  An  irregular  temperature 
record  may  occur  with  increased  frequency  of  the  pulse. 

In  fatal  cases,  the  termination  is  ushered  in  with  delirium, 
convulsions,  stupor,  coma,  and  other  symptoms  resembling 
hydrocephalus . 

Diagnosis. — The  distinctive  features  of  this  affection  are  the 
fever,  abdominal  distention  and  tenderness,  emaciation,  and  the 
characteristic  "chopped  spinach"  stools.  Cholera  infantum 
may  be  confused  with  it,  but  the  rapid  onset,  high  temper- 
ature, persistent  vomiting,  profuse  serous  stools,  and  early 
collapse  in  the  former  affection  will  serve  to  differentiate  these 
conditions. 

Prognosis. — Enterocolitis  is  always  a  serious  affection.  The 
acute  cases  usually  subside  in  from  ten  days  to  two  weeks, 
while  the  chronic  forms  last  from  one  to  three  months  or  longer. 
Relapses  are  frequent.  In  vigorous  children  who  have  passed 
their  first  dentition  the  outlook  is  favorable,  but  in  weak  in- 
fants surrounded  by  unhygienic  environments,  the  prognosis 
is  grave.  The  prompt  institution  of  appropriate  treatment 
favorably  influences  the  prognosis. 

Treatment. — The  feeding  should  be  first  temporarily  withheld 
and  afterward  altered  to  suit  the  individual  needs  of  the 
patient.  When  possible,  a  change  of  air,  with  cleanliness  and  rest, 
is  desirable.  The  intense  suffering  of  the  little  patients  calls  for 
anodynes,  and  the  progressive  emaciation  indicates  the  use  of 
whiskey  or  brandy  (10  to  20  minims)  every  three  or  four  hours. 
The   following    formulas   may   also  be  used   with   advantages : 


ENTEROCOLITIS.  273 

I^.      Salol gr.  ij  .  13  gm. 

Bismuthi  subnitrat gr.  v  .32  gm. 

M.     Ft.  chart.  No.  i. 

S. — Such  a  powder  every  two  hours. 

Or— 

I^.      Hydrarg.  chlorid.  mit.  .  .    gr.  ss  .032  gm. 

Pulv.  ipecac gr.  ss  .032  gm. 

Pulv.  opii gr.  ss  .  03  2  gm. 

Cretae  praeparat gr.  xx  i  .3       gm. 

M.     Ft.  chart.  No.  xij. 

S. — One  every  two  or  three  hours,  to  child  of  one  year. 

The  compound  kino  powder,  lactic  acid,  and  subnitrate  of 
bismuth  in  small  but  frequently  repeated  doses  may  be  of 
benefit. 

The  following  is  a  good  combination: 

I^.      Bismuthi  subnitrat 3iij  12 ,  gm. 

Tinct.  kino f  §iss  45.  c.c. 

Tinct.  opii  camphorat.  .  .   f§iss  45.  c.c. 

Mist,  cret^ 3iij  90.  c.c. 

M.  S. — Tablespoonful  every  few  hours. 

Flushing  of  the  colon  with  cold  normal  salt  solution,  or  solu- 
tions containing  silver  nitrate  (i  gr.  to  the  ounce),  tannic  acid 
(5  gr.  to  the  ounce),  or  sodium  benzoate  (4  gr.  to  the  ounce) 
is  an  extremely  valuable  part  of  the  treatment.  For  tenesmus, 
Rotch  advises  suppositories  containing  1/4  gr.  of  cocain.  The 
abdominal  pain  and  distress  may  be  relieved  by  the  application 
of  hot  water-bottles,  mustard  plasters,  turpentine  stupes,  or 
the  spice  poultice.  The  spice  poultice  is  made  up  of  1/2  ounce 
(15.6  gm.)  each  of  cloves,  allspice,  cinnamon,  and  anise  seeds, 
which  are  pounded  together  in  a  mortar  and  placed  between 
two  pieces  of  coarse  flannel  about  6  inches  square.  This 
should  be  soaked  in  equal  parts  of  hot  whiskey  or  brandy  and 
water  and  then  applied  to  the  abdomen,  being  again  heated  as 
it  becomes  cool. 

The  chronic  form  differs  but  slightly  in  its  treatment  from  the 
18 


2  74  CHOLERA   INFANTUM. 

acute  form.  The  diet  requires  considerable  attention,  to  alter 
and  predigest  the  artificial  foods  to  meet  the  various  indica- 
tions. Fresh  air,  salt  baths,  cleanliness,  and  other  details 
of  hygiene  demand  consideration.  Among  drugs,  bismuth, 
pepsin,  and  salicin  will  be  found  of  benefit.  The  following 
formulas  may  also  be  employed: 

I^.     Argenti  nitrat gr.  j  .065  gm. 

Acid,  nitric,  dil ttlxv  i  .  c.c. 

Mucil.  acaciae f  oss  15.  c.c. 

Aq.  cinnamomi ad  f  Siij  ad  90.  c.c. 

M.  S. — Teaspoonful,  diluted,  every  three  or  four  hours. 

Or— 

I^.      Acidi  carbolici gr.  i/i2toi/8.oo5to.  008  gm. 

Tincturae  iodi vrij  to  ij  .06    to  .  12.  c.c. 

Aquae  menthae  pip f  o  j  4  .  c.c. 

M.  S. — Every  three  or  four  hours. 

Or— 

I^.      Quininae  hydrochlorid .  .  .    gr.  xxv  i .  6  gm. 

Acid,  tannici gr.  x  .6  gm. 

Sjrr.  limonis f  oij  8  .     c.c. 

Aq.  chloroformi.  .q.  s.  ad  f  5iij  ad  12.     c.c. 
M.  S. — Teaspoonful  every  two  hours. 

CHOLERA  INFANTUM. 

Synonyms. — Choleriform    diarrhea;    summer   complaint. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach  and  intestines,  together  with  an  irrita- 
tion of  the  sympathetic  nervous  system,  occurring  in  children 
during  the  first  dentition ;  characterized  by  severe  colicky  pains  , 
vomiting,  purging,  febrile  reaction,  and  prostration. 

Causes. — Hot  weather,  infancy,  dentition,  improper  food,  bad 
hygiene,  and  constitutional  predisposition  are  the  most  im- 
portant causes.  The  exciting  cause  is  probably  some  specific 
microorganism  or  its  toxin.  Several  varieties  of  bacteria  have 
been  found  in  this  disease,  but  no  one  alone  has  as  yet  been 
identified  as  the  cause. 


CHOLERA   INFANTUM.  275 

Pathologic  Anatomy. — There  are  no  characteristic  lesions, 
the  gastrointestinal  mucous  membrane  is,  however,  usually 
the  seat  of  catarrhal  inflammation. 

Symptoms. — The  onset  is  sudden,  being  ushered  in  with  vom- 
iting, purging,  abdominal  pain,  high  fever  (103°  to  105°  F.j, 
rapid  pulse,  and  intense  thirst.  The  vomited  matter  consists 
of  partly  digested  food,  sero-mucus,  and  finally  bilious  material. 
Distressing  retching  accompanies  the  vomiting.  The  tongue 
is  coated.  Thirst  is  a  marked  feature  of  the  disease,  and  ice 
and  water  will  be  taken  incessantly  for  its  relief  only  to  be  re- 
jected a  few  minutes  later.  The  stools  are  first  partly  fecal, 
but  soon  become  watery  or  serous,  soaking  the  clothing  and 
leaving  a  faint  greenish  or  yellowish  stain.  They  number  from 
ten  to  twenty  a  day  and  possess  a  musty  and  at  times  fetid 
odor.  The  temperature  should  be  taken  in  the  rectum,  as  the 
surface  temperature  is  comparatively  low.  The  pulse  is  rapid 
and  feeble,  ranging  from  130  to  160  per  minute.  These  various 
symptoms  continue  but  a  few  hours  before  rapid  wasting  ensues. 
The  body  shrinks,  the  eyes  are  shrunken  and  partly  closed,  the 
mouth  partly  open,  and  the  lips  are  dry,  cracked,  and  bleeding. 
The  child  is  at  first  irritable  and  restless,  but  soon  passes  into 
a  semicomatose  condition,  the  pulse  becoming  more  and  more 
feeble;  the  body  surface  is  cold  and  clammy;  the  pupils  contract, 
but  are  irresponsive  to  light;  and  the  stupor  deepens.  The 
termination  may  be  in  death  with  profound  exhaustion  or 
convulsive  seizures,  or  in  recovery,  the  symptoms  gradually 
ameliorating  and  passing  into  a  slow  and  tedious  convalescence. 

Diagnosis. — The  characteristics  of  cholera  infantum  which 
serve  to  distinguish  it  from  other  enteric  affections  are  the  rapid 
onset,  the  constant  serous  vomiting  and  purging,  the  intense 
thirst,  the  high  fever,  prostration,  and  rapid  emaciation. 

Prognosis. — The  outlook  is  unfavorable.  Many  cases  end 
by  collapse  within  twenty-four  to  forty-eight  hours.  The 
choleraic  symptoms  never  last  more  than  five  days,  and  if  the 
patient  survives  this  period,  recovery  after  a  protracted  con- 
valescence is  probable.      Relapses  are  common. 

Treatment. — The  first  indication  is  to  thoroughly  empty  the 


276  CHOLERA   INFANTUM. 

digestive  tract  by  washing  out  the  stomach  and  irrigating  the 
bowel  with  cold  water.  Morphin,  gr.  i/ioo  (0.00065  gni.), 
and  atropin,  gr.  1/500  (0.000132  gm.),  may  be  given  hypoder- 
mically  to  a  child  one  year  old,  to  comjDat  the  nervous  and  car- 
diac symptoms.  Normal  salt  solution  should  be  administered 
by  the  bowel  or  by  hypodermoclysis.  The  fever  will  require 
cool  bathing,  or  sponging  with  alcohol  and  water,  and  the  appli- 
cation of  an  ice-bag  to  the  head.  In  the  early  stages  it  is  best 
to  withhold  feeding;  later  brandy,  ttlv  to  x  (0.3  to  0.6  c.c), 
and  barley  water  should  be  given  every  hour.  If  the  stomach 
is  absolutely  unretentive,  the  stimulation  should  be  administered 
hypodermically.  The  vomiting  may  be  controlled  to  a  greater 
or  less  extent  by  large  doses  of  bismuth  or  chloral,  gr.  i  to  iii 
(0.065  ^o  0.21  gm.)  by  the  mouth  in  a  demulcent,  or  double 
the  quantity  by  the  rectum,  or  one  of  the  following: 

I^.      Bismuth,  subnitrat 5ij  8.         gm. 

Acid,  carbolici gr.j  .065  gm. 

Mist,  acaciae, 

Aq.  menth.  pip aa  f  5j  aa  30.  c.c. 

M.  S. — Teaspoonful  every  half  hour,  hour,  or  two  hours. 

Or— 

I^.      Hydrarg.  chlorid.  mit.  .  .    gr.  1/20      .003  gm. 

Bismuth,  subnitrat gr.  ij  to  v  .  13  to  .  3.  gm. 

M.  S. — A  powder  every  half  hour. 

Benefit  may  also  be  obtained  from  the  use  of  bismuth 
salicylate,  gr.  ii  (0.13  gm.),  with  sugar  of  milk  every  hour  or 
two,  or  salol,  gr.  i  to  ii  (0.065  "to  o-i3  gi^^-)  every  two  or  four 
hours.  -When  depression  supervenes  the  feeding  should  be 
every  two  hours;  water  or  ice  should  be  given  to  quench  the 
thirst;  and  cognac  brandy,  ti^v  to  x  (0.3  to  0.6  c.c),  should  be 
administered  every  hour  or  two  by  the  mouth,  rectum,  or  hypo- 
dermic injection.  In  the  event  of  collapse,  the  hot  bath  should 
be  employed  and  a  hypodermic  injection  of  strychnin  (gr: 
i/ioo  or  0.00065  gm.  to  a  one-year-old  child),  should  be  given. 


APPENDICITIS.  277 

The  nervous  symptoms  when  marked  may  require  potassium 
bromid  or  valerian. 

Locally,  the  application  of  hot  water-bottles,  mustard  or  spice 
poultice,  or  turpentine  stupes  to  the  epigastrium  will  afford 
relief. 

During  convalescence  a  change  of  air  is  of  great  benefit. 
Every  detail  of  the  hygiene  should  be  improved.  Peptonized 
milk  should  be  given  for  a  long  period,  substituted  occasionally 
by  barley-water,  albumin-water,  and  fresh  beef -juice.  The 
feeding  should  be  carefully  watched  and  modified  from  time  to 
time  as  the  occasion  arises. 

APPENDICITIS. 

Synonyms. — Perityphlitis ;  typhlitis. 

Definitions. — Typhlitis  really  means  inflammation  of  the 
cecum.  Perityphlitis,  an  acute  inflammation  of  the  connective 
tissue  around  the  cecum. 

■  Appendicitis. — An  acute  or  subacute  inflammation  of  the  ap- 
pendix vermiformis,  involving  the  surrounding  tissues.  But 
typhlitis  is  merely  an  extension  of  appendicitis,  and  the  term 
should  be  abolished. 

Causes. — Fecal  impaction,  foreign  bodies,  errors  in  diet,  acute 
indigestion,  exposure,  intestinal  catarrh,  male  sex,  early  adult 
life  and  the  peculiar  anatomy  of  the  appendix  are  the  principal 
predisposing  causes.  The  exciting  cause  is  a  microorganism, 
in  all  probability  the  Bacillus  coli  communis,  but  streptococci, 
staphylococci,  and  the  Proteus  vulgaris  have  been  associated 
with  it.  It  may  follow  tuberculosis,  typhoid  fever,  or  influenza, 
in  which  cases  the  exciting  cause  is  probably  the  bacterium 
which  produced  the  preceding  infectious  fever.  Torsion  of  the 
appendix  may  be  a  cause. 

Pathologic  Anatomy. — The  inflammation  of  the  appendix 
may  be  catarrhal,  ulcerative,  or  interstitial. 

Catarrhal  appendcitis  consists  in  a  desquamative  inflam- 
mation of  the  mucous  membrane,  which  becomes  swollen  and 
sometimes  obliterates  the  lumen  of  the  tube.      In  some  cases  the 


278  APPENDICITIS. 

excoriated  surface  becomes  the  avenue  of  infection  and  the  dis- 
ease terminates  in  an  acute  infectious  peritonitis. 

Ulcerative  appendicitis  is  characterized  by  varying  grades  of 
ulceration  of  the  mucous  membrane  and  submucous  tissue,  and 
may  terminate  in  perforation.  It  is  not  infrequently  associated 
with  fecal  concretions  and  foreign  bodies.  Typhoid  and 
tubercular  ulcerations  may  be  encountered. 

Interstitial  or  parietal  appendicitis  may  have  its  origin  in  an 
abraded  or  ulcerated  surface  of  the  mucous  membrane,  or  it  may 
arise  independently  in  the  structure  of  the  appendix  wall,  the 
infection  being  carried  by  the  lymphatics.  It  is  extremely 
virulent  and  is  commonly  associated  with  necrosis  or  gangrene 
of  the  appendix  wall,  thereby  leading  to  perforation  and  a 
virulent  type  of  peritonitis.  It  may  terminate  fatally  before 
the  necrosis  becomes  manifest. 

In  all  forms  there  is  a  localized  or  generalized  peritonitis, 
which,  by  its  resultant  adhesions,  aims  to  wall  off  the  infection 
from  the  general  peritoneal  cavity.  In  the  mild  forms  this  is 
accomplished  to  a  great  extent,  but  in  severe  cases  in  which  pus 
forms  and  the  appendix  ruptures,  these  adhesions  for  a  time 
form  the  walls  of  an  abscess;  but  they,  too,  ultimately  rupture, 
discharging  the  contents  of  the  abscess  into  the  peritoneal 
cavity,  bowel,  bladder,  vagina,  or  externally.  Sometimes  the 
exudate  into  the  tissues  surrounding  the  appendix  is  absorbed. 

Symptoms. — The  affection  begins  with  a  feeling  of  weight  and 
soreness  and  rapidly  developing  severe  pain  over  the  entire 
abdomen,  but  most  marked  in  the  right  iliac  region.  The 
pain  is  increased  by  coughing,  deep  breathing,  and  by  lying  on 
the  left  side,  so  that  for  relief  the  right  leg  drawn  up  and  the 
dorsal  decubitus  assumed.  Localized  tenderness  accompanies 
the  pain  and  corresponds  to  the  situation  of  the  diseased  struc- 
ture. Usually  it  may  be  detected  by  palpation  at  a  point  mid- 
way between  the  umbilicus  and  the  anterior  superior  spine  of 
the  ilium  (McBurney's  point).  In  the  early  stage,  there  is 
rigidity  of  the  right  abdominal  rectus  muscle  and  adjacent 
muscles,  which  rigidity  is  replaced  in  two  or  three  days  by 
an  oval  tumor,  usually  about  the  size  of  a  hen's  egg,  lying  in 


APPENDICITIS.  279 

the  right  iliac  region,  parallel  to  Poupart's  ligament.  Per- 
cussion over  this  enlargement  yields  impaired  resonance  or 
dullness.  Occasionally  the  note  is  normal.  Nausea  and  vomit- 
ing are  frequent  and  often  occur  early  in  the  attack.  The 
tongue  becomes  coated  and  the  appetite  is  lost.  Constipation 
is  the  rule,  but  it  may  be  replaced  by  diarrhea.  Fever  (102°  to 
104°  F.)  is  present  from  the  onset  and  may  or  may  not  be  pre- 
ceded by  a  chill.  There  is  a  corresponding  increase  in  the  pulse 
rate.  Suppuration  is  usually  manifested  by  irregular  fever 
and  chills,  sweats,  and  a  feeling  of  tension  or  throbbing  in  the 
region  of  the  appendix,  but  may  be  unattended  by  fever.  Gan- 
grene of  the  appendix  may  occur  in  the  presence  of  a  normal 
temperature.  A  sudden  fall  in  the  temperature  usually  indi- 
cates perforation  of  the  structure.  The  urine  has  the  charac- 
teristics of  fever  urine,  and  in  addition  contains  a  large  quantity 
of  indican.      Leukocytosis  is  present  in  most  cases. 

Complications. — Obstruction  of  the  bowels  is  the  most  impor- 
tant complication.  Local  or  general  peritonitis,  perforation, 
and  abscess  formation  are  the  most  common  complications. 
Localized  peritonitis  gives  rise  to  adhesions  which  may  produce 
intestinal  obstruction.  Generalized  peritonitis  may  result 
from  extension  of  the  inflammation  or  rupture  of  the  appendix. 
The  symptoms  of  the  resulting  general  peritonitis  are:  "  i. 
Diffuse  pain,  as  contrasted  with  pain  localized  in  the  right 
iliac  region — pain  of  extreme  severity.  2.  Generally  distended 
and  tender  abdomen.  3.  Moderate  fever,  succeeded  by 
normal  or  subnormal  temperature,  which  may  often  mislead 
the  physician.  4.  Rapid  and  feeble  pulse.  5.  Dry  and  coated 
tongue.  6.  The  phenomena  of  collapse — i.e.,  cold,  clammy 
skin,  feeble  pulse,  anxious  expression,  death." 

Suppuration  of  the  appendix  may  be  followed  by  generalized 
peritonitis,  hepatic  abscess,  lumbar  abscess,  perinephritic 
abscess,  or  multiple  pyemic  abscesses.  Chronic  appendicitis, 
in  which  the  attacks  recur  at  intervals,  is  a  common  sequel 
in  cases  in  which  the  appendix  is  left  undisturbed. 

Diagnosis. — The  diagnosis  is  often  difficult.  Sudden  pain, 
tenderness,  muscular  rigidity,  and  fever  are  the  main  symptoms. 


28o  APPENDICITIS. 

Rovsings  sign  may  be  useful  in  differentiating  acute  appendicitis 
from  other  lesions  of  the  lower  abdomen  such  as  salpingitis. 

It  is  thus  given  by  Tyson :  '  'Pressure  over  the  descending  colon 
at  a  point  opposite  the  cecum  will  give  pain  in  the  appendix 
region  if  the  case  is  appendicitis,  but  will  not  give  pain  if  the 
case  is  any  other  lesion." 

Typhoid  fever  is  distinguished  from  appendicitis  by  its  more 
gradual  onset,  the  characteristic  temperature  record,  diarrhea, 
enlargement  of  the  spleen,  rose-colored  abdominal  rash,  and 
the  Widal  reaction. 

Intestinal  obstruction  is  unattended  by  fever,  there  is  no 
localized  tenderness,  constipation  is  more  complete,  the  pain  is 
diffuse,  and  the  vomiting  may  be  stercoraceous. 

Rectal  growths,  tubal  disease,  and  ovarian  tumors  may  be 
recognized  and  differentiated  from  appendicial  inflammation  by 
physical  examination  by  rectum  and  vagina;  and  see  Rovsing's 
sign  above. 

Acute  indigestion  is  characterized  by  an  absence  of  localized 
pain  and  tenderness.  Diarrhea  is  common  and  there  is  no 
enlargement  in  the  right  iliac  region. 

Hepatic  colic  is  attended  by  jaundice  and  intermittent  pain 
higher  up  in  the  abdomen  extending  to  the  right  shoulder. 
Fever  is  usually  absent. 

Nephritic  colic  is  marked  by  an  absence  of  fever  and  localized 
rigidity  and  by  paroxysmal  pain  extending  from  the  lumbar 
region  into  the  groin  and  testicle. 

Hepatic  and  renal  abscesses  may  be  distinguished  by  their  loca- 
tion and  character  of  the  pain.  They  often  occur  as  the  result 
of  a  suppurating  perityphlitis  and  frequently  are  only  recog- 
nized after  the  abdomen  has  been  opened. 

Prognosis. — The  outlook  depends  entirely  on  the  character  of 
the  disease  and  the  treatment.  In  non-suppurative  cases 
recovery  is  the  rule.  Suppurative  cases,  in  which  surgical 
treatment  has  been  instituted,  show  a  mortality  of  about  25 
per  cent.  The  mortality  is  75  per  cent,  in  the  presence  of 
generalized  peritonitis.  In  operations  between  the  attacks  the 
mortality  is  less  than  i  per  cent. 


PROCTITIS.  261 

Treatment. — As  soon  as  the  diagnosis  has  been  made  (and 
even  before  this)  a  competent  surgeon  should  be  associated 
with  the  physician,  as  it  is  difficult  to  predict  the  termination 
even  in  apparently  mild  cases.  The  patient  should  be  placed 
at  rest  in  bed  and  the  diet  restricted  to  liquids.  In  the  early 
stages  a  mild  laxative,  such  as  castor  oil,  calomel,  or  citrate 
of  magnesia  may  be  administered.  In  advanced  cases  purga- 
tion may  induce  perforation.  Enemas  may  be  cautiously  used. 
Heat  or  cold  applied  to  the  abdomen  will,  in  a  measure,  relieve 
the  pain.  Morphin,  hypodermically,  may  be  necessary,  but 
it  should  be  remembered  that  it  masks  important  symptoms. 
If  the  symptoms  do  not  subside  under  this  plan  of  treatment 
within  twenty-four  or  forty-eight  hours,  it  is  customary  to 
resort  to  a  surgical  operation.  Some  surgeons  operate  as  soon 
as  the  diagnosis  is  made.  In  mild  cases  in  which  the  symptoms 
abate  and  the  attack  is  the  first  one,  the  operation  may  be 
postponed  until  the  interval  between  the  attacks.  If  the  symp- 
toms become  less  in  severity,  but  do  not  entirely  subside, 
operation  is  indicated  at  once  Complicated  cases  also  require 
immediate  operation.  No  definite  rules  can  be  followed  in 
appendicitis,  each  case  possessing  features  which  place  it  in 
a  class  by  itself.  In  cases  in  which  it  is  certain  an  operation 
will  not  be  performed,  counterirritation  may  be  applied  to  the 
abdomen. 

PROCTITIS. 

Synonyms. — Catarrh  of  the  rectum;  dysentery;  rectitis. 

Definition. — A  catarrhal  inflammation  of  the  mucous  mem- 
brane of  the  rectum  and  anus;  characterized  by  pain,  tenesmus, 
and  frequent  stools  of  hardened  feces,  or  of  mucus,  pus,  and  blood. 

Causes. — It  may  arise  from  constipation,  habitual  use  of 
enemas  and  purgatives,  diseases  of  the  liver,  hemorrhoids,  and 
sitting  on  damp  ground  or  stone  steps. 

Symptoms. —  Burning  pain  in  the  rectum,  tenesmus,  the 
passage  of  hardened  feces,  or  stools  containing  mucus,  muco- 
pus,  or  blood,  and  prolapse  of  the  mucous  membrane  are  the 
most   prominent   symptoms.      Nausea,    headache,  feverishness, 


282  INTESTINAL    OBSTRUCTION. 

and  malaise  may  be  present.  In  severe  cases  strangury  and 
vesical  tenesmus  may  be  present,  and  periproctitis  and  fistulas 
may  occur  if  the  affection  is  protracted.  Hepatic  abscess  and 
peritonitis  may  arise  as  complications. 

Diagnosis. — Physical  examinr  tion  of  the  rectum  will  serve  to 
distinguish  it  from  hemorrhc  i  -.  and  uterine  displacements, 
which  are  somewhat  similar  a;     egards  their  symptomatology. 

Prognosis. — The  outlook  is  favorable  in  uncomplicated  cases. 

Treatment. — As  constipation  is  the  most  common  cause  it 
should  be  relieved  by  a  soap  and  warm  water  enema,  rectal 
irrigations,  or  the  following  injection: 

I^.      Magnesii  sulphat 5ij  60.  gm. 

Glycerini f  §ss  15  .  c.c. 

Aquae  bul ••••  foiv  120.  c.c. 

M.  S. — Use  as  directed. 

Glycerin  may  be  employed  in  suppository  or  enema,  or  the 
following  emollient  enema  may  be  used: 

I^.      01.  oliv« f  §ij  60.  c.c. 

Tinct.  opii  deodorat  ....     nxxv  i  .  c.c. 

M.  S. — Use  as  directed. 

Hot  injections  of  strong  black  coffee,  using  from  a  half  pint 
to  a  quart,  are  valuable  in  irritability  of  the  rectum  with  a 
tendency  to  diarrhea.  Occasionally  cold  injections  are  more 
beneficial. 

If  periproctitis  and  suppuration  supervene  early  incision  is 
indicated. 

INTESTINAL  OBSTRUCTION. 

Definition. — A  sudden  or  gradual  closure  of  the  intestinal 
canal;  characterized  by  pain,  nausea,  vomiting,  constipation, 
and  finally  collapse.  Obstruction  to  the  descent  of  fecal  matter 
is  the  main  idea ;  but  frequent  loose  bowel  movements  may  occur 
in  intussusception  and  other  forms. 

Varieties. — a.  Acute  obstruction,  produced  by  (i)  strangula- 
tion, (2)  intussusception  (or  invagination),  (3)  twists  and  knots 


INTESTINAL    OBSTRUCTION.  283 

(volvulus),  (4)  foreign  bodies,  (5)  strictures,  and  (6)  morbid 
growths.      Acute  obstruction  usually  involves  the  small  intestine. 

b.  Chronic  obstruction,  p)roduced  by  (i)  fecal  impaction, 
(2)  strictures,  (3)  morbid  growths.  Chronic  obstruction  in- 
volves the  large  intestine. 

Causes. — The    numerous    causes    are    arranged    as    follows: 

1 .  Strangulation  is  the  most  frequent  cause  of  acute  intestinal 
obstruction,  and  is  most  often  due  to  inflammatory  bands  or 
adhesions,  vitelline  remains,  adherent  appendix,  and  peritoneal 
pouches  and  openings.  Most  cases  occur  in  males,  and  after 
the  twentieth  year;  if  it  occurs  in  early  youth  it  is  usually 
caused  by  vitelline  remains. 

2.  Intussusception  or  invagination  is  due  to  one  portion  of 
the  intestine  slipping  down  into  the  lumen  of  another  portion, 
always  from  above  downward;  it  may  even  protrude  at  the 
rectum.  The  external  or  receiving  portion  is  the  intussuscip- 
iens;  the  inner  parts  form  the  intussusceptum. 

3.  Twists  and  Knots  (Volvulus). — As  a  rule,  the  intestine  is 
twisted  on  its  long  or  mesenteric  axis;  knots  occur  rarely.  It 
is  most  frequent  in  adult  males,  between  the  ages  of  thirty  and 
forty;  and  the  large  intestine  is  usually  involved. 

4.  Foreign  Bodies. — The  majority  of  these  are  gallstones 
(and  these  are  more  frequent  in  females) ;  but  lumbricoid 
worms,  medicines  such  as  large  doses  of  magnesia  and  bismuth, 
and  rarely  substances  introduced  by  the  mouth  (such  as  pennies , 
buttons,  pins,  fruit  stones,  etc.)  are  also  found. 

5.  Strictures  and  6.  Morbid  Growths. — These  occur  in  adults, 
and  are  generally  found  in  the  large  intestine.  Strictures 
may  be  congenital  or  cicatricial;  the  latter  are  due  to  healed 
ulcers,  tubercular  or  syphilitic.  Morbid  growths  may  be  benign 
or  malignant,  may  occur  within  or  without  the  lumen  of  the 
intestine;  the  most  frequent  is  epithelioma,  near  the  sigmoid 
flexure. 

7.  Fecal  obstruction  occurs  more  often  in  females,  and  is 
found  in  the  large  intestine  (chiefly  the  lower  part).  It  is  due 
to  constipation,  chronic  enteritis  and  peritonitis,  imperfect 
digestion,  and  nervous  influences. 


284  INTESTINAL   OBSTRUCTION. 

Pathologic  Anatomy. — Invagination  calls  for  special  descrip- 
tion. It  is  usually  caused  by  the  lower  portion  of  the  ileum 
slipping  down  into  the  cecum,  as  the  finger  of  a  glove  might  be 
invaginated,  causing  thus  an  actual  mechanical  obstruction; 
this  is  produced  by  a  spasm  of  the  ileum,  whereby  its  caliber  is 
greatly  diminished,  thus  permitting  its  descent  into  the  lower 
bowel.  Resulting  from  this  occlusion  or  compression,  are 
congestion,  inflammation,  with  secondary  constitutional  reac- 
tion and  death,  or  more  rarely  the  invaginated  bowel  sloughs 
off  and  is  voided  by  stool,  union  taking  place  at  its  site  and 
recovery  following. 

Symptoms. — In  acute  cases,  sudden  spasmodic  abdominal 
pain  which  soon  becomes  continuous  in  character  is  an  early 
symptom.  Constipation,  which  is  unrelieved  by  purgatives 
or  enemas,  is  present;  and  there  is  inability  to  pass  flatus.  The 
abdomen  becomes  greatly  distended  and  very  tender  in  spots. 
Nausea  and  vomiting  occur,  the  vomit  persisting  and  at  length 
becoming  stercoraceous.  In  intussusception,  there  is  a  char- 
acteristic tumor,  generally  found  in  the  left  iliac  region.  In 
gallstone  obstruction,  jaundice  is  often  present.  As  the  condi- 
tion progresses,  pinched  features,  sunken  eyes,  quick,  feeble 
pulse,  cold,  clammy  skin,  and  other  symptoms  of  collapse  be- 
come manifest.  The  duration  of  this  form  is  about  a  week  or 
ten  days,  when  death  may  occur,  or  more  rarely  the  symptoms 
may  subside  and  there  is  a  gradual  return  to  health. 

In  chronic  cases  obstinate  constipation,  with  the  passage  of 
ribbon-shaped  stools  or  scybalous  masses,  abdominal  pain  and 
distention  and  failure  of  health  are  the  principal  symptoms. 
The  onset  is  gradual.  It  may  become  acute  when  the  obstruc- 
tion is  complete.  In  rare  instances  small,  fecal,  muco-purulent 
stools,  containing  more  or  less  blood,  are  passed. 

Diagnosis. — The  features  of  intestinal  obstruction  that  are 
of  most  value  in  making  a  diagnosis  are  the  obstinate  constipa- 
tion, the  early  vomiting,  which  shortly  becomes  stercoraceous 
in  character,  the  abdominal  distention,  the  absence  of  any 
discharge  of  flatus  by  the  bowel,  and  early  collapse.  The  x-vary 
may  aid  in  locating  the  obstruction. 


INTESTINAL    OBSTRUCTION.  285 

Acute  peritonitis  resembles  intestinal  obstruction  to  some 
extent,  but  the  fever,  diffuse  tenderness,  and  the  absence  of 
a  tumor  and  fecal  vomiting  point  to  peritonitis. , 

Strangulation  in  hernia  is  attended  by  the  same  symptoms  as 
intestinal  obstruction,  and  in  the  event  of  their  occurrence 
the  various  abdominal  rings  should  be  carefully  examined. 
The  less  common  situations  of  hernia,  such  as  the  obturator 
foramen  and  the  sciatic  notch,  should  also  be  investigated. 
Sometimes  internal  strangulation  results  from  a  portion  of 
the  intestine  slipping  through  the  foramen  of  Winslow,  the 
diaphragm,  or  a  slit  in  the  omentum  or  mesentery,  or  under 
Meckel's  diverticulum,  or  from  inflammatory  adhesions. 

The  situation  of  the  obstruction  may  be  indicated  by  the 
presence  of  a  tumor.  Fecal  vomiting  usually  points  to  obstruc- 
tion of  the  small  intestine.  Active  peristalsis  is  always  present 
a  short  distance  above  the  obstruction. 

The  nature  of  the  obstruction  in  many  instances  may  be  deter- 
mined indirectly.  In  the  large  intestine  more  than  one-half  the 
cases  of  obstruction  are  due  to  intussusception,  about  one-third 
to  twists,  and  about  one-eighth  to  stricture  and  tumors.  In  the 
small  intestine  nearly  three-fourths  of  the  cases  result  from 
strangulation,  about  one-sixth  from  gallstones,  and  about  one- 
twelfth  from  intussusception.  In  children  intussusception  is 
the  most  common  cause  of  obstruction.  It  may  be  recognized 
by  the  sausage-shaped  tumor  along  the  colon,  and  by  digital 
examination  by  the  rectum.  Obstruction,  due  to  twists, 
malignant  growths,  and  strictures  is  usually  low  down  and 
may  be  detected  by  rectal  examination.  The  history  of  attacks 
of  peritonitis  will  point  to  inflammatory  adhesions  as  the  cause 
of  the  obstruction.  Alteration  in  the  thoracic  percussion-note 
will  indicate  the  passage  of  a  portion  of  the  bowel  through  the 
diaphragm.  Marked  meteorism  in  the  right  inguinal  region 
is  considered  to  be  a  diagnostic  symptom  of  obstruction  by 
Meckel's  diverticulum.  Fecal  impaction  is  distinguished  by  its 
gra,dual  onset  and  course,  the  history,  and  of  an  irregular  tumor 
along  the  line  of  the  colon. 

The  table  on  page  286  will  aid  in  making  a  diagnosis. 


286 


INTESTINAL    OBSTRUCTION. 


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INTESTINAL  PARASITES.  287 

Prognosis. — The  prognosis  is  always  grave  but  is  most  favor- 
able in  fecal  impactions.  In  invagination  the  outlook  is  less 
favorable,  but  recoveries  occur;  the  longer  the  symptoms  con- 
tinue the  more  favorable  becomes  the  prognosis.  Strangula- 
tion and  stricture  are  very  grave  conditions. 

Treatment. — In  all  acute  forms  of  obstruction,  food  and 
cathartics  should  be  withheld.  Morphin  and  atropin,  hypo- 
dermically,  and  warm  applications  to  the  abdomen  will  be 
required  to  relieve  the  pain.  The  stomach  should  be  washed 
out  two  or  three  times  daily,  and  in  doubtful  cases  the  colon 
may  be  irrigated  with  warm  water.  Distention  of  the  colon 
with  gas  may  be  employed  in  suspected  intussusception.  Nutri- 
ent enemas  may  be  resorted  to  to  sustain  the  patient.  An 
abdominal  operation,  performed  early,  is  perhaps  the  best 
treatment  in  acute  cases. 

In  chronic  obstruction,  efforts  should  be  made  to  remove  the 
fecal  tumor.  Large  rectal  injections  of  warm  water  or  warm 
oil  are  very  efficient.  The  administration  of  calomel,  gr.  1/8 
(0.008  gm.),  every  hour  is  an  additional  aid.  The  rectal  scoop 
may  be  employed  if  the  obstruction  is  low  down.  Massage 
and  electricity  are  often  of  value.  Surgical  intervention  may 
be  necessary. 

INTESTINAL  PARASITES. 

Parasites  are  low  forms  of  organisms  (animal  or  vegetable) 
which  live  in  or  on  other  animals  (called  the  host),  and  deriving 
their  nourishment  from  the  tissues  and  juices  of  their  host. 
That  part  of  the  body  of  the  host  in  which  the  parasite  takes  up 
its  abode  is  called  its  habitat.  The  organism  in  which  the 
immature    forms    are    lodged    is    called    the   intermediate   host. 

TAPEWORMS— CESTODES. 

Varieties. — There  are  several  varieties  of  tapeworm  which 
infest  man,  but  only  the  following  are  of  importance:  Taznia 
saginata;  Tcsnia  solium;  Dihothriocephalus  latus;  Tcsnia  echino- 
coccus. 


288  TAPEWORMS — CESTODES. 

Natural  History. — In  most  cases  the  lower  animals  are  the 
intermediary  hosts  by  ingesting  food  infected  by  the  tapeworm. 
The  embryos  or  proscolices  of  these  parasites  are  liberated  in 
the  stomach  and  from  thence  migrate  to  the  miuscles  and  various 
organs,  becoming  encapsulated,  constituting  scolices,  or  cys- 
ticerci.  Meat  infected  by  these  encysted  larvae  is  said  to  be 
"measly."  When  ingested  by  man  the  capsules  are  dis- 
solved and  the  scolices  are  liberated  and  become  attached  to 
the  mucous  membrane  of  the  digestive  tract  and  there  develop 
into  mature  tapeworms. 

Causes. — The  Tcenia  saginata,  called  also  the  Tcsnia  medio- 
canellata,  the  "unarmed  tapeworm,"  is  derived  from  the  em- 
bryos contained  in  beef,  known  as  Cysticercus  hovis.  This  is 
the  form  most  frequently  met  with  in  this  country. 

The  TcBnia  solium,  the  "armed  tapeworm,"  is  extremely 
rare  in  this  country;  the  popular  impression  that  it  is  quite 
common  is  erroneous.  It  is  derived  from  the  embryos  con- 
tained in  pork,  known  as  the  Cysticercus  celluloses. 

The  Dibothriocephalus  latus,  or  B othriocephalus  latus,  also  an 
"unarmed  tapeworm,"  the  largest  parasite  infesting  man,  is 
supposed  to  be  derived  from  an  embryo  found  in  fish. 

The  Tcenia  echinococcus  occurs  in  its  natural  state  in  the  in- 
testines of  the  dog,  the  larval  condition  only  being  encountered 
in  man. 

Faulty  preparation,  improper  cooking,  and  lack  of  cleanliness 
as  regards  the  food  and  drink  are  important  etiologic  factors. 

Description. — The  Tcenia  saginata  or  TcEnia  mediocanellata  is 
from  ten  to  thirty  feet  in  length,  and  has  several  hundred  pro- 
glottides. It  has  a  rounded  or  oval-shaped  head  which  measures 
about  i/io  of  an  inch,  and  has  four  strong  and  prominent  suck- 
ers, but  no  hooklets — whence  the  term  "unarmed  tapeworm" ; 
the  neck  is  short  and  thick  and  the  segments  are  larger,  stronger, 
and  thicker  than  those  of  the  Tcsnia  solium.  The  best  way  to 
distinguish  a  segment  of  Tcsnia  saginata  from  that  of  TcEnia 
solium-   is   to   count   the   number   of  lateral    uterine   branches. 

In  the  Tcsnia  saginata,  there  are  15  to  30  of  them;  in  the 
T(Bnia  solium,  there  are  5  to  10.      (See  Fig.  21.) 


TAPEWORMS — CESTODES. 


289 


The  TcBnia  solium  seldom  exceeds  12  feet  in  length,  has  a 
globular  head,  or  scolex,  a  slender  neck  connecting  its  numerous 
flat  segments  or  joints.  The  head,  or  scolex,  measures  about 
1/40  of  an  inch,  has  a  double  circle  of  hooklets — whence  the 
term  "armed  tapeworm" — and  is  provided  with  from  two  to 
four  suckers.      The  segments  or  joints   (strobila)    are  flat,   and 


O.-U.'^Vid'vn.of      1-0% 


Fig.  21. — Tapeworms.  A.  i,  2  and  3,  Scolex,  proglottides  and  ovum  of  Tcsnia 
solium;  B.  4,  5,  6  and  7,  Scolex,  proglottides  and  ovum  of  Diboihriccephalus  latus; 
C.  8,  9  and  ro,  Scolex,  proglottides  and  ovum  of  TcBnia  saginata.  {From  Stitfs  Practical 
Bacteriology.) 


vary  from  i  /8  to  i  /2  inch  in  length,  and  each  contains  both 
male  and  female  sexual  organs,  the  uterus  being  a  long,  nu- 
merously branched  tube,  in  which  the  ova  develop;  the  ova 
measure  about  1/1700  inch  in  diameter.  An  ordinary  tape- 
worm contains  some  5,000,000  ova.  The  parasite  is  firmly 
embedded  in  the  mucous  membrane  of  the  upper  third  of   the 

19 


290 


TAPEWORMS — CESTODES. 


small  intestines  by  its  hooklets  and  suckers.  The  lower  or 
terminal  segments  represent  the  adult  and  complete  animal, 
and  are  termed  the  proglottides,  which  separate  from  the  para- 
site and  are  discharged  either  alone  or  with  the  feces. 

The  Dibothriocephahis  I  at  us  is  the  largest  of  the  three  cestodes, 
the  length  ranging  from  15  to  60  feet,  the  head  oval,  meas- 
uring about  i/io  inch,  a  short  neck,  the  segments  or 
joints  being  nearly  three  times  as  broad  as  they  are  long. 
There  are  said  to  be  3000  or  more  of  these  segments.  Its  color 
is  a  dull,  bluish-gray. 

The  Tcenia  echinococcus  is  one  of  the  smallest  tapeworms 
known,  being  about  1/6  inch  long,  and  is  composed  of  three  or 
four  segments,  of  which  only  the  end  segment  is  ma.ture.  It 
is  2  mm.  long  and  0.6  mm.  wide  and  contains  about  5000  ova. 
The  head  is  provided  with  a  rostellum,  two  rows  of  hooklets, 
and  four  suckers.  The  adult  worm  is  com- 
mon to  dogs  in  Iceland  and  Australia ;  human 
beings  are  affected  only  by  the  embryos, 
which,  on  being  liberated  in  the  digestive 
tract,  migrate  toward  the  periphery,  par- 
ticularly the  liver,  where  they  form  hydatid 
cysts.      (See  page  311.) 

Symptoms. — Xot    infrequently    there    are 
no     symptoms.        In    many    cases,    colicky 
pains,    inordinate     or     capricious    appetite, 
disorders  of  digestion,   emaciation,   anemia, 
constipation,   cardiac  palpitation,   faintness, 
disorders  of  the  special  senses,  choreic  move- 
ments, convulsive   seizures,  and  pruritus  of 
the  anus  and  nose  are  present,  more  or  less 
combined.      The  ingestion  of  a  large  meal  often  removes  most 
of  these  symptoms.      The  presence  of  one  or  more  segment  of 
the  tapeworm  in  the  stools  is  conclusive. 

Treatment. — This  consists  in  giving  first  something  to 
paralyze  the  worm,  and  then  something  to  expel  it.  The 
administration  of  an  anthelmintic  is  necessary  but  should  be 
preceded  by  restriction  of  the  diet  to  liquids  for  one  or  two  days 


Fig.  22. — Taenia  echi- 
nococcus. {From  Greene  s 
Medical  Diagnosis .) 


ROUND  WORMS — NEMATODES.  291 

with  free  purgation.     Probably  the  best  teniafuge  is  oleoresin 
of  aspidium,  foss  (2  c.c),  alone  or  in  combination, 

I^.      Oleoresinae  aspidii f5ij  8.       c.c. 

Chloroformi f  5ij  8 .       c.c. 

Olei  tiglii n\iv  .  24  c.c. 

Glycerini f  §ij  60.        c.c. 

M.  S. — Take  half  at  8  a.  m.;  the  rest  in  an  hour  if  needed 
(Dock). 

Kousso,  oi  (30  gm.j,  in  a  half  pint  of  water,  fiuidextract  of  the 
bark  of  the  root  of  pomegranate,  f5ss  (2  c.c.),  decoction  of  the 
bark  of  the  pomegranate  root — §i  (30  gm.)  to  the  pint  (480  c.c.) 
of  water — in  divided  doses,  or  the  tannate  of  pelletierine,  gr. 
X  to  XX  (0.65  to  1.3  gm.),  may  be  used  instead.  A  purgative 
should  be  also  given  after  the  anthelmintic  and  the  stools  care- 
fully watched  for  the  head  of  the  parasite.  Sometimes  the 
head  may  not  be  found,  because  (being  very  small)  it  is  lost  in 
the  discharges.  The  head  of  the  Tcsnia  solium  is  about  the  size 
of  a  small  pin's  head;  in  the  Tcsnia  saginata  it  is  a  little  larger; 
and  in  the  Dibothrioce phahis  laUts  it  is  still  larger. 


ROUND  WORMS— NEMATODES. 

General  Characters. — The  round  worms  are  round  and  thread 
like,  they  resemble  earthworms;  the  male  is  smaller  than  the 
female;  the  genital  pore  is  situated  in  the  female  about  the 
middle  of  its  length,  and  near  the  anus  in  the  male. 

Varieties. — The  most  common  are:  Ascaris  lumbricoides ; 
Oxyttris  vermicularis ;  Trichina  spiralis;  Anchylostoma  duodenale; 
Filaria  sanguinis  hominis;  Trichocephalus  dispar. 

Causes; — The  Ascaris  lumbricoides  is  the  most  common  of 
the  parasites  affecting  the  human  family,  and  develops  in  the 
intestines,  either  after  the  entrance  of  the  ova  of  the  same, 
or  from  the  so-called  "intermediate  parasites."  Their  entrance 
is  effected  by  means  of  the  food  and  drink. 

The   Oxyuris   vermicularis   develops   in    the   large  intestines, 


292 


ROUND    WORMS — NEMATODES. 


from  either  its  peculiar  ova  or  the  so-cahed  "intermediate  para- 
site," these  finding  their  way  into  the  bowel  with  the  food  and 
drink,  or  by  direct  contact. 

The  Trichina  spiralis  is  introduced  into  the 
human  body  by  eating  infected  hog's  flesh, 
either  raw  or  but  partly  cooked. 

The  Anchylostoma  duodenale  gains  access 
to  the  digestive  tract  by  means  of  drinking 
water  infected  by  the  ova.  It  is  common  in 
the  miners  and  brickmakers  in  Europe,  Egypt, 
and  India. 

The  Filiaria  sanguinis  honiinis  is  common 
in  tropical  countries,  the  medium  of  infection 
being  contaminated  drinking  water.  The 
parasites  are  found  in  the  intestines  of 
mosquitoes,  and  on  the  sixth  or  seventh  day 
of  their  development  they  change  their 
habitat  to  water,  through  the  death  of  the 
intermediary  host. 

The  Trichocephalus  dispar  is  one  of  the 
most  common  parasites  in  man,  having 
for  its  habitat  the  cecum.  The  ova  are  very  resistant  to 
destructive  agents  and  are  found  in  large 
numbers  in  the  feces.  Infected  drinking 
water  is  probably  responsible  for  this  parasite 
in  man. 

Description. — The  Ascaris  lumbricoides,  looks 
very  much  like  the  ordinary  earthworm,  it  is  of 
a  brownish  color,  having  a  cylindrical  body, 
pointed  at  both  ends,  from  4  to  10  or  15  inches 
in  length,  and  from  i  /8  to  i  /4  inch  in  circum- 
ference the  head  terminates  in  three  semilunar 
lips,  each  having  about  200  teeth.  The  ova 
are  oval-shaped,  are  produced  in  immense 
numbers  (some  60,000,000  in  a  mature  female), 
have  wonderful  vitality,  resisting  extreme  heat  or  cold.  The 
round  worm  inhabits  principally  the  small  intestines,  although 


Fig.     23. — Ascaris 
lumbricoides.       (a)    fe- 
male, (b)  male,  (c)  egg, 
(d)     head.         (Greene's 
Medical  Diagnosis.) 


Fig.  24. — Oxyuris 
vermicularis.  (a)  fe- 
male, (b)  male. 
(Greene's  Medical 
Diagnosis.) 


ROUND    WORMS — NEMATODES. 


293 


it  often  migrates  to  other  parts.      They  are  found  in  numbers 
from  one  to  several  hundred. 

The  Oxyuris  vermicularis ,  thread,  or  seat  worm,  resembles 
an  ordinary  piece  of  white  thread,  measuring  from  1/6  to  1/2 
inch  in  length,  the  head  terminating  in  a  mouth  with  three 
lips,  the  tail  terminating  as  a  sharp  point.  The  ova  are  oval, 
produced  in  large  numbers,  each  female  containing  about  ten 
thousand,  and  are  surrounded  by  a  stout  envelope,  which  in- 
creases their  vitality.      The  seat  worm,   as  its  name  indicates. 


Fig.  25. — Trichina  spiralis,  (a)  en- 
cysted in  muscle,  (b)  male  adult,  (c) 
female  adult  (personal  observation) , 
(d)  male  genital  apparatus.  (Greene  s 
Medical  Diagnosis', 


Fig.  26. — Uncinaria  (anchylostoma) 
duodenale.  (a)  female,  (b)  male,  (c) 
eggs,  (d)  male  and  female  of  natural 
size.     {Greene's  Medical  Diagnosis .) 


inhabits  the  large  intestines,  especially  the  rectum,  although 
they  frequently  migrate  to  the  sexual  organs.  They  vary  in 
number,  the  parts  frequented  being  entirely  covered. 

The  Trichina  spiralis  presents  itself  in  two  forms;  the  in- 
testinal trichina  which  is  sexually  mature  and  the  muscle 
trichina  which  is  sexually  immature. 

The  Intestinal  trichina  is  a  small,  hair-like  worm,  the  male 
measuring  1/18  inch,  and  the  female  1/8  inch  in  length;  the 
head  is  smaller  than  the  rest  of  the  body ;  the  tail  of  the  male 
has  a  bi-lobed  prominence,  between  the  divisions  of  which  the 


294  ROUND    WORMS — NEMATODES. 

anal  opening  is  placed,  and  from  which  a  single  spiculum  can 
be  protruded;  the  female  has  a  blunt,  rounded  tail,  the  repro- 
ductive outlet  being  situated  toward  the  anterior  part  of  the 
body;  the  ova  are  very  small  (about  1/170  inch  long),  containing 
embryos  which  are  produced  viviparously  at  the  rate  of  at 
least  100  each  week  after  the  entrance  of  the  female  into  the 
intestinal  canal. 

The  muscle  trichina  develops  its  sexual  apparatus  after  it  has 
entered  the  intestinal  canal  of  the  host.  .  The  viable  embryos 
discharged  from  the  female  are  in  a  state  of  motion,  and  at 
once  migrate  from  the  intestines  to  the  muscular  structure  of 
the  individual,  and  here  set  up  inflammatory  action,  soon  becom- 
ing surrounded  by  a  capsule  or  shell  in  which  they  are  coiled. 
After  a  time,  in  the  muscle,  the  trichina  undergoes  a  further 
change,  lime  salts  being  deposited  in  and  about  the  capsule  and 
in  the  parasite  itself,  when  minute  specks  of  lime  are  seen  dis- 
tributed throughout  the  muscular  structure. 

The  development  of  the  parasite  from  the  period  of  impreg- 
nation up  to  time  of  sexual  maturity  is,  under  favorable  condi- 
tions, less  than  three  weeks.  Within  two  days  from  the  inges- 
tion of  the  infected  pork  occurs  the  maturation  of  the  muscle 
larvae;  in  six  days  more  the  birth  of  embryos  occur,  and  in 
about  two  weeks  the  migrating  progeny  have  arrived  at  their 
habitat,  the  muscular  structure. 

The  Anchylostoma  duodenale  is  a  short,  white,  cylindrical  worm 
found  in  the  upper  part  of  the  small  intestine.  The  female 
is  about  1/2  inch  long,  and  the  male  about  1/3  inch. 

The  Filaria  sanguinis  honiinis  is  an  extremely  small  parasite 
and  occurs  in  several  forms.  In  the  principal  form  (Filaria 
Bancrofti  or  Filaria  nocturna)  the  adult  male  is  83  mm.  long 
and  0.4  mm.  wide;  the  female  is  about  155  mm.  long  and  0.7 
mm.  wide.  The  ovum  is  0.038  mm.  long  and  0.014  mm.  wide. 
The  adult  worm  is  found  usually  in  the  lymphatics.  The  female 
produces  an  enormous  number  of  embryos  which  migrate  to 
various  portions  of  the  body  and  are  found  in  the  blood  stream 
only  during  the  sleeping  hours,  usually  at  night. 

The  Trichocephalus  dispar  is  a  delicate,  hair-like  worm  4  to 


ROUND    WORMS NEMATODES.  295 

5  cm.  long,  the  posterior  two-fifths  being  the  thickest  portion. 
The  terminal  extremity  of  the  female  is  conical  and  pointed, 
while  that  of  the  male  is  obtuse  and  round.  The  ova  are 
0.05  mm.  long  and  oval  in  shape,  provided  with  a  small  teat- 
like projection. 

Symptoms. — The  Ascaris  lumbricotdes,  may  be  present  in 
great  numbers  and  yet  produce  no  characteristic  symptoms 
other  than  gastric  and  intestinal  irritation,  causing  picking 
the  nose,  foul  breath,  colicky  pains,  nausea  and  vomiting, 
diarrhea,  and  disturbed  sleep,  such  as  tossing  from  side  to  side 
in  bed  and  grinding  the  teeth.  Any  or  all  of  these  symptoms 
may  be  present  or  absent;  a  positive  diagnosis  is  only  possible 
upon  the  passage  of  the  parasite.' 

The  Oxytiris  vcrmicitlaris,  or  seat  worm,  produces  intense 
itching  about  the  anus,  with  a  desire  for  stool,  the  passages 
often  containing  much  mucus,  the  result  of  the  irritation  pro- 
duced by  the  parasite.  Should  it  migrate  to  the  sexual  organs, 
intense  itching  of  these  parts  results,  which,  unless  speedily 
corrected,  leads  in  children  to  masturbation. 

The  group  of  phenomena  produced  by  the  Trichina  spiralis 
is  known  as  trichiniasis  and  presents  itself  in  three  stages. 

Intestinal  stage,  a  gastrointestinal  inflammation,  with  nausea, 
vomiting,  and  watery  diarrhea,  the  severity  depending  upon 
the  number  of  the  parasites  ingested. 

Migration  stage,  a  typhoid-like  fever,  rapid,  feeble  pulse, 
profuse  sweats,  intense  thirst,  dry  tongue  and  lips,  and  red, 
swollen  face,  with  soreness  and  tenderness  of  the  muscular 
structure,  increased  by  any  muscular  act.  As  a  rule  the  mind 
is  clear  but  decidedly  apathetic. 

Encapsulation  Stage. — If  the  number  of  parasites  ingested 
has  been  few,  recovery  may  occur  in  this  stage;  but  if  the  num- 
ber has  been  large,  the  gastroenteritis,  fever,  and  muscular 
phenomena  are  severe,  the  patient  is  in  a  critical  condition, 
between  20  and  50  per  cent,  succumbing. 

Trichiniasis  may  resemble  typhoid  fever,  in  that  the  patient 
has  fever,  headache,  stupor,  pain  in  limbs,  back,  and  abdomen, 
nausea  and  diarrhea. 


296  ROUND    WORMS — NEMATODES. 

In  trichiniasis,  there  is  an  eosinophilia;  therefore  in  all  sus- 
pected cases  a  differential  blood  count  should  be  made.  The 
trichina  may  be  found  in  muscle  tissues. 

The  Anchylostoma  duodenale  is  a  blood-sucking  parasite.  It 
fastens  itself  to  the  mucous  membrane  of  the  digestive  tract 
and  at  first  produces  colicky  pains,  diarrhea,  and  other  symp- 
toms of  gastrointestinal  irritation.  The  loss  of  blood  induced 
by  the  parasite  leads  to  anemia  (Egyptian  chlorosis,  tunnel 
anemia),  emaciation,  and  weakness.  This  disease  is  also  called 
Uncinariasis,  or  Anchylostomiasis,  or  Hookworm  disease.  The 
infection  may  be  carried  by  contaminated  food  or  cistern  water, 
also  (from  the  soil),  by  the  feet,  body,  or  dirty  clothes;  thus  it 
gains  entrance  through  the  skin.  The  parasites  inhabit  the  in- 
testinal tract  and  their  ova  may  be  found  in  the  stools.  The 
disease  is  most  prevalent  in  the  southern  part  of  the  United 
States  and  in  some  instances  is  said  to  have  followed  ground- 
itch.  Malaria  may  be  associated.  The  principal  symptom  is 
anemia  which  is  considered  by  most  observers  to  be  toxic  in 
origin.  Leukocytosis  is  uncommon,  but  an  increase  in  the 
eosinophiles  is  rather  frequent.  The  skin  has  a  dirty,  grayish 
pallor  considered  by  many  to  be  characteristic. 

The  Filaria  sanguinis  ho  minis  gives  rise  to  a  condition  known 
as  Filariasis  which  is  characterized  by  anemia,  enlargement  of 
the  spleen,  fever,  chyluria,  hematuria,  lymphatic  obstruction, 
and  elephantiasis. 

The  Trichocephalus  dispar  may  be  unattended  by  symp- 
toms, or  may  be  accompanied  by  slight  gastrointestinal  irri- 
tation, anemia,  cerebral  manifestations,  and  in  rare  instances 
beri-beri. 

Treatment. — The  Ascaris  lumbricoides  is  readily  removed  by 
the  following  "worm  powder": 

I^.  Santonini gr.  1/4  to  j  to  ij    .  016  to  .  065  to  .  13  gm. 

Hydrarg.  chlorid.  mitis.  gr.  1/3  toij  .022  to  .13  gm. 

M.     Ft.  chart. 

S. — At  bedtime,  followed  by  a  dose  of  castor  oil  before 
breakfast. 


ROUND    WORMS — NEMATODES.  297 

For  the  Oxyiiris  vermicularis  the  above  santonin  powder,  with 
the  use  of  enemas  of  quassia,  alum,  salt,  or — 

J\       Acidi  carbolici gr.  v  to  x  .  3  to  6  gm. 

Glycerin rr^v  to  x  • .  3  to  .  6  c.c. 

Aquae Oj  480.  c.c. 

M.   S. — For  rectal  injection. 

An  enema  of  corrosive  sublimate  (i  to  10,000)  is  sometimes 
employed.  The  rectal  injection  should  not  be  retained  and 
should  always  be  preceded  by  a  large  enema  of  water  to  thor- 
oughly cleanse  the  bowel.  Washing  of  the  anus  and  external 
genitals  with  a  carbolic  acid  solution  is  often  useful  and  aids 
in  allaying  the  intense  itching. 

In  Trichiniasis,  the  pork  should  be  so  prepared  as  to  kill  any 
existing  trichina.  If  the  patient  is  seen  within  four  or  five 
days  after  the  ingestion  of  the  parasites,  emetics,  purgatives, 
lavage,  and  intestinal  irrigation  are  indicated.  Following  these 
procedures  vermicides  may  be  administered,  such  as  glycerin 
(i  part)  and  water  (2  parts),  oi  or  4  c.c.  every  hour,  benzine, 
5i  (4  gm.),  in  capsules,  quinin,  and  santonin.  The  muscular 
pains  may  be"  relieved  by  hot  applications  and  morphin 
hypodermically.  Tonics  and  stimulants  are  necessary  to 
sustain  the  patient.  The  mortality  ranges  from  5  to  30 
per   cent. 

Anchylostomiasis  or  Uncinariasis  requires  thorough  boiling 
of  the  drinking  water  in  districts  known  to  be  infected.  Thy- 
mol, gr.  XXX  (2  gm.),  in  divided  doses  followed  by  a  purgative, 
seems  to  have  a  specific  action;  filix  mas  is  also  used.  The 
anemia  calls  for  rest,  iron,  quinin,  strychnin,  arsenic,  etc.  Pro- 
phylaxis includes  filtering  and  boiling  water,  cleansing  of  all 
vegetable  foods,  avoidance  of  going  barefooted,  and  disinfection 
of  stools  of  infected  persons.  Bathing  and  the  wearing  of  clean 
clothes  and  shoes  are  of  great  importance. 

Filariasis  is  most  difficult  to  treat.  The  symptoms  should 
be  met  as  they  rise.  Thymol  and  methylene  blue  may  be  tried. 
As    prophylactic     measures    mosquitoes    should    be    destroyed 


298  DISEASES  OF  THE  LIVER. 

as     for    malaria,     houses    screened,     and    water    filtered     and 
boiled. 

Trichoce phalli s  dispar  requires  no  special  treatment. 


DRACONTIASIS   (GUINEA-WORM  DISEASE). 

Dracontiasis  is  the  term  applied  to  the  group  of  morbid  phe- 
nomena induced  by  the  presence  in  the  body  of  the  Filaria  or 
Dracunculus  medinensis .  The  female  parasite  alone  is  known. 
It  enters  the  system  through  the  stomach  and  migrates  to  the 
subcutaneous  connective  tissue  especially  of  the  lower  extremi- 
ties near  the  ankles,  where  it  matures.  After  a  period  of 
quiescence  it  excites  suppuration  and  abscess  formation.  The 
embryos  are  discharged  and  in  some  manner  find  their  way  to 
sources  of  water.  Here  they  are  probably  taken  up  by  a  small 
crustacean  (cyclops).  Infected  drinking  water  is  the  cause  of 
the  disease  in  man.  No  race,  age,  or  sex  is  exempt.  The 
treatment  consists  in  opening  the  abscesses  and  removing  the 
wormi  and  its  embryos  intact.  Injections  of  bichlorid  of  mer- 
cury (i  to  1000)  are  of  value. 


DISEASES  OF  THE  LIVER. 

Preliminary  Considerations — Normally,  the  greater  portion 
of  the  liver  is  situated  in  the  right  upper  quadrant  of  the  abdo- 
men, a  small  portion  extending  over  the  median  line  into  the 
left  upper  quadrant.  Percussion  over  the  area  occupied  by 
the  liver  yields  a  dull  note.  Absolute  liver  dullness  extends  in 
the  median  line  from  the  lower  border  of  cardiac  dullness  to 
midway  between  the  ensiform  appendix  and  the  umbilicus;  in 
the  mammillary  line  from  the  upper  border  of  the  sixth  rib  to  the 
costal  margin ;  in  the  axillary  line  from  the  eighth  to  the  eleventh 
rib;  and  posteriorly  from  the  tenth  to  the  eleventh  rib.  This 
is  graphically  shown  in  a  table  by  Hutchinson  and  Rainy,  as 
follows : 


DISEASES    OF    THE    LIVER. 


299 


Upper 
limit. 


Lower 

limit. 


Middle  line. 


Mammillary 
line. 


Midaxillary 
line. 


Scapular 
line. 


Deep  / 

dullness.   1 

Superficial  J 
dullness.    1 


Blends  with 
heart 
dullness. 

Hand's 
breadth  be- 
low base  of 
xiphoid. 


Fourth  space  .|  Seventh  space .     Ninth  space. 


Sixth  rib Eighth  rib.  .  .  .     Tenth  rib. 


Costal    margin}   Tenth  space 
or    somewhat: 
above   or  be-j 
low  it. 


Blends  with 
kidney 
dullness. 


The  situation  of  the  liver  may  be  altered  as  the  result  of  trans- 
position of  the  viscera,  tight  lacing,  ascites,  abdominal  tumors, 
pleurisy,  or  emphysema.  Varying  degrees  of  displacement 
may  be  encountered.  Floating  liver  is  a  rare  condition  of  this 
kind,  in  which  relaxation  and  elongation  of  its  ligaments  per- 
mit it  to  fall  from  its  normal  position,  especially  when  the  erect 
posture  is  assumed.  Tight  lacing  and  pendulous  abdomen  are 
given  as  causes.  The  organ  is  recognized  in  its  new  position 
by  its  shape  and  dullness  and  its  absence  from  the  normal 
situation  aids  in  confirming  the  diagnosis. 

The  principal  abnormality  in  shape  of  the  liver  is  that  known 
as  ''corset-liver  '  or  the  ''  laced- off  liver  which  results  from  the 
wearing  of  tight  waist  bands  and  corsets.  It  is  characterized  by 
division  of  the  right  lobe  into  two  almost  equal  parts  by  a 
transverse  furrow.  The  connection  between  the  two  parts  is 
in  very  rare  cases  reduced  to  a  fibrous  band.  The  affection  is 
most  common  in  women  and  seems  to  favor  cholelithiasis. 
There  are  no  symptoms,  as  a  rule,  and  the  possibility  of  this 
condition  should  be  considered  in  examining  for  floating  kidney, 
and  other  visceral  displacements. 

In  the  physical  examination  of  the  liver  it  should  be  remem- 
bered that  normally  the  edge  of  the  liver  is  seldom  felt  by  the 
examining  fingers  except  in  thin  and  emaciated  subjects  and 
in  young  children.  It  becomes  palpable  when  enlarged  or 
displaced  from  any  cause.  Irregularities  of  the  surface  of  the 
liver  suggest  the  possibility  of  cancer,   syphilis,   abscesses,   or 


300  CONGESTION    OF    THE   LIVER. 

hydatids.  Alterations  in  the  consistency  of  the  hepatic  struc- 
ture are  indicative  of  certain  changes,  thus  in  cancer,  congestion, 
hypertrophic  cirrhosis,  and  amyloid  infiltration,  the  liver  is  more 
dense;  while  in  abscesses  and  hyatid  cysts  the  consistency  is 
less,  particularly  in  the  diseased  area.  If  in  the  examination 
tenderness  is  elicited,  it  points  to  the  presence  of  congestion, 
inflammation,  abscess  formation,  or  cancer.  Pulsation  is 
occasionally  encountered  and  is  nearly  always  due  to  passive 
congestion  following  tricuspid  regurgitation,  but  it  may  also 
be  due  to  aneurysm  or  a  tumor  in  close  proximity  to  the  ab- 
dominal aorta  which  transmits  its  pulsation. 

The  size  of  the  liver  may  give  an  indication  of  the  character 
of  the  affection  in  many  instances;  thus  hypertrophic  cirrhosis, 
congestion,  cancer  when  diffuse,  and  fatty  and  amyloid  condi- 
tions produce  a  more  or  less  uniform  enlargement  of  the  organ ; 
in  cancer,  gumma,  abscess,  hydatid  cysts,  and  similar  affec- 
tions the  enlargement  is  somewhat  nodular  in  character;  and 
in  atrophic  and  degenerative  conditions  the  organ  undergoes 
diminution  in  size.  An  apparent  enlargement  may  occur  when 
the  liver  dullness  is  increased  by  any  pulmonary  condition 
that  displaces  the  organ  downward,  and  an  apparent  diminu- 
tion may  be  observed  when  the  liver  dullness  is  obscured  by 
tympanites  from  any  cause,  or  by  pulmonary  or  subcutaneous 
emphysema. 

CONGESTION  OF  THE  LIVER. 

Synonyms. — Torpid  liver;  biliousness. 

Definition. — An  abnormal  fullness  of  the  vessels  of  the  liver, 
with  consequent  enlargement  of  that  organ;  it  is  termed  active 
when  arterial ;  passive  when  venous.  The  condition  is  character- 
ized by  torpidity  of  the  digestive  and  mental  functions,  and 
slight  jaundice. 

Causes. — Active  congestion;  heat,  atmospheric  or  artificial; 
habitual  constipation;  malaria;  excesses  in  eating  and  drinking; 
alcoholic  or  malt  liquors.  In  females,  an  arrested  menstrual 
epoch  may  give  rise  to  an  attack. 


I 


CONGESTION    OF    THE    LIVER.  30I 

Passive  congestion;  cardiac  and  pulmonary  diseases. 

Pathologic  Anatomy. — The  liver  is  enlarged  in  all  directions, 
and  is  abnormally  full  of  blood.  Cases  due  to  obstructive 
diseases  of  the  heart  or  lungs  present  the  so-called  "nutmeg 
liver"  appearance.  At  the  center  of  each  lobule  the  dilated 
radicle  of  the  hepatic  vein,  enlarged  and  congested,  may  be  dis- 
cerned, v^hile  the  neighboring  parts  of  the  lobule  are  pale,  the 
radicles  of  the  portal  vein  containing  less  blood.  Long- 
continued  congestion  establishes  atrophic  degeneration  or 
cyanotic  induration  of  the  organ;  the  decrease  in  size  is  con- 
founded with  the  condition  of  cirrhosis;  but  the  "atrophic  liver" 
is  smooth,  while  the  "cirrhotic  liver"  is  nodulated. 

Symptoms. — Acute  congestion  begins  with  malaise,  aching  of 
the  limbs,  feverishness,  headache,  depression  of  spirits,  coated 
tongue,  anorexia,  nausea,  and  sometimes  vomiting.  Con- 
stipation and  flatulence  are  present,  and  there  is  a  feeling  of 
fullness,  weight,  and  soreness  in  the  hepatic  region  with  dull 
pain  extending  to  the  right  shoulder.  The  liver  is  uniformly 
enlarged  and  tender.  The  complexion  is  muddy  and  there  may 
be  slight  jaundice.     The  attack  usually  lasts  about  a  week. 

Passive  congestion  is  characterized  by  similar  symptoms  but 
of  less  severity.  The  onset  is  gradual  and  gastrointestinal 
catarrh  is  common.  In  addition,  there  are  the  symptoms  of 
the  causal  heart  or  lung  disease. 

Prognosis. — The  acute  attacks  end  favorably,  but  if  there  is 
a  constant  repetition  of  them  atrophic  degeneration  is  the  usual 
result.  Passive  congestion  is  dependent  entirely  upon  the  sever- 
ity of  its  cause  for  its  prognosis.  In  many  cases  atrophic  de- 
generation or  cyanotic  induration  follows. 

Treatment. — In  acute  attacks  induced  by  dietetic  indis- 
cretions the  following  mixture  should  be  given: 

I^.      Sodii  bicarb gr.  v  .3  gm. 

Pulv.  ipecac gr.  ss  .  03  gm. 

Hydrargyri  chloridi  mit.   gr.  iij  to  v    .2  to  .3  gm. 
M.  S. — To  be   taken  at  one  dose  and   followed  in  about  two 
hours  by  a  saline  cathartic,  or  by  sodium  phosphate,  5i  (4  gm.). 


302  ABSCESS    OF    THE    LIVER. 

After  free  purgation  has  been  brought  about  the  following 
should  be  administered: 

I^.     Acid,  nitro-hydrochloric.  dil .  n\x        .6  c.c. 

Elix.  taraxaci  comp f5ij    8.    c.c. 

M.  S. — To  be  taken  about  a  half-hour  before  meals. 

Malarial  cases  should  receive  appropriate  doses  of  quinin  and 
patients  with  chronic  heart  or  lung  disease  should  be  treated 
according  to  the  necessities  of  the  individual  case.  In  all 
chronic  cases,  rest,  liquid  diet,  free  purgation  with  salines  or 
cholagogues,  and  cupping  will  be  of  benefit.  Strychnin  sul- 
phate and   sodium  arsenate  may  also  be  employed  internally. 

In  acute  attacks,  hot  applications  and  sinapisms  may  be 
applied  over  the  region  of  the  liver. 

ABSCESS  OF  THE  LIVER. 

Synonyms. — Suppurative  hepatitis;  parenchymatous  hepa- 
titis; acute  hepatitis. 

Definition. — A  diffused  or  circumscribed  inflammation  of  the 
hepatic  cells,  resulting  in  suppuration,  the  abscesses  being 
sometimes  single,  at  times  double;  characterized  by  irregular 
febrile  attacks,  hepatic  tenderness,  and  symptoms  of  deranged 
gastrointestinal  and  hepatic  functions. 

Causes. — The  exciting  causes  are  pathogenic  bacteria, 
particularly  the  ameba  coli,  colon  bacillus,  staphylococcus, 
and  streptococcus.  In  most  cases  the  portal  circulation  is  the 
transmitting  medium  of  the  infection.  In  amebic  dysentery, 
the  microorganisms  reach  the  liver  and  produce  suppuration 
through  this  system  of  vessels.  Infectious  thrombi  and  emboli 
from  any  area  drained  by  the  portal  system,  when  carried  to 
the  liver  give  rise  to  purulent  inflammation  and  abscesses. 
This  is  sometimes  seen  in  gastric  and  duodenal  ulcers,  purulent 
appendicitis,  and  similar  affections  of  the  digestive  tract. 
Infectious  emboli  from  ulcerative  endocarditis,  pyemia,  pul- 
monic conditions,  osteomyelitis,  injuries,  etc.,  may  reach  the 
liver    through    the    hepatic    artery,  and    abscesses    result.      In 


ABSCESS    OF    THE    LIVER.  303 

the  new-born  infant,  umbilical  phlebitis  may  terminate  in 
hepatic  suppuration.  Suppuration  of  an  hydatid  cyst,  sup- 
puration following  impacted  gall-stones,  and  traumatism  may 
also  be  causes  of  liver  abscesses.  Dysentery  is  the  most  com- 
mon of  all  the  etiologic  factors. 

Pathologic  Anatomy. — If  the  condition  is  the  result  of  dysen- 
tery or  injury  there  will  be,  as  a  rule,  but  one  abscess  and  it  will 
in  most  cases  occupy  the  right  lobe.  In  those  cases  due  to 
pyemia  and  similar  conditions,  there  will  be  multiple  abscesses. 
As  the  abscess  progresses  it  tends  to  rupture  and  may  burst 
into  the  peritoneum,  intestines,  stomach,  gall-bladder,  hepatic 
duct  or  vein,  pleura,  or  lungs,  or  it  may  perforate  the  abdominal 
wall  and  discharge  externally.  After  the  pus  has  been  evacu- 
ated cicatrization  occurs.  Sometimes  the  pus  is  absorbed 
and  the  abscess  replaced  by  a  scar,  but  more  frequently 
absorption  of  the  pus  is  attended  by  septicemia. 

Symptoms. — The  constitutional  manifestations  include  irreg- 
ular intermittent  fever  or  remittent  fever,  chills,  sweats,  ob- 
stinate vomiting,  gastrointestinal  disorders,  constipation,  light- 
colored  stools,  slight  jaundice,  irritability  of  the  nervous  system, 
melancholia,  anemia,  leukocytosis,  and  in  marked  cases  typhoid 
symptoms. 

The  local  symptoms  consist  of  hepatic  enlargement  upward, 
circumscribed  bulging,  pain  extending  to  the  right  shoulder, 
tenderness,  and  fluctuation.  When  the  abscess  tends  to  burst 
externally,  the  area  over  it  becomes  hot,  red,  tender,  sw^ollen, 
and  edematous. 

Diagnosis. — In  doubtful  cases  the  aspirator  may  be  employed. 
Cancer  is  distinguished  by  its  longer  course,  history,  nodular  en- 
largement of  the  liver,  emaciation,  cachexia,  and  the  absence  of 
septic  phenomena. 

Intermittent  fever  is  characterized  by  definite  paroxysms,  en- 
largement of  the  spleen,  and  the  presence  of  malarial  organisms 
in  the  blood. 

Hepatic  intermittent  fever  differs  from  hepatic  abscess  in  its 
history  of  several  attacks,  its  le^s  serious  course,  biliary  colic, 
and  obstinate  jaundice. 


304  ACUTE  YELLOW  ATROPHY. 

Pleural  effusion  on  the  right  side  may  be  differentiated  from 
hepatic  abscess  by  diminished  fremitus  and  vocal  resonance,  and 
bronchial  breathing  if  the  lung  is  compressed. 

Hydatid  cyst  differs  from  abscess  in  its  slower  course,  the 
absence  of  septic  symptoms,  and  the  withdrawal  of  clear  fluid 
and  hooklets  on  aspiration.  In  the  presence  of  suppuration, 
the  finding  of  the  hooklets  is  alone  diagnostic. 

Prognosis. — In  traumatic  and  amebic  abscesses  when  the  pus 
can  be  evacuated  early,  a  favorable  termination  may  occur,  but 
in  pyemic  and  other  forms  the  affection  is  fatal. 

Treatment. — Palliative  measures  such  as  the  administration 
of  nutritious  food,  iron,  quinin,  strychnin,  and  alcohol  should 
be  prescribed.  When  the  abscess  is  single  and  can  be  definitely 
located  it  should  be  evacuated  and  drained. 

ACUTE  YELLOW  ATROPHY. 

Synonyms. — Parenchymatous  hepatitis;  malignant  jaundice; 
hemorrhagic  icterus. 

Definition. — An  acute,  diffused,  or  general  inflammation  of 
the  hepatic  cells,  resulting  in  their  complete  disintegration; 
characterized  by  diminution  in  the  size  of  the  liver,  deep 
jaundice,  hemorrhages,  and  profound  disturbance  of  the  ner- 
vous system,  terminating  in  death,  usually  within  one  week. 

Causes. — The  cause  is  unknown.  The  affection  is  apparently 
due  to  the  presence  of  some  very  toxic  agent  in  the  blood.  It  is 
very  rare  and  occurs  with  greatest  frequency  in  young  pregnant 
women  from  the  third  to  the  sixth  month  of  gestation.  Among 
the  other  causes  may  be  mentioned  infectious  diseases,  alcoholic 
and  venereal  excesses,  syphilis,  mental  excitement,  and  poison- 
ing by  phosphorous,  arsenic,  or  antimony.  Bacteria  have 
been  found  in  the  organ  after  death.  Autodigestion  has  also 
been  suggested  as  the  cause. 

Pathologic  Anatomy. — In  the  early  stage  there  is  hyperemia 
of  the  hepatic  cells  with  a  grayish  exudation  between  the  lobules. 
The  organ  becomes  soft  and  friable  and  of  a  dull  yellow  color. 
The  cells  rapidly  disappear  being  replaced  by  fat  globules  and 


CIRRHOSIS    OF    THE    LIVER.  305 

the  liver  is  reduced  in  size  and  weight.  Hemorrhagic  extrava- 
sations are  present.  The  peritoneal  covering  of  the  liver  is 
loose  and  thrown  into  folds.  The  spleen,  kidneys,  heart, 
and  muscles  undergo  parenchymatous  degeneration.  The 
urine  is  loaded  with  bile  pigment  and  the  blood  contains  a 
large  amount  of  urea  and  considerable  leucin. 

Symptoms. — The  early  stage  of  this  condition  resembles  an 
attack  of  acute  catarrhal  jaundice,  being  attended  at  first  by 
gastrointestinal  catarrh,  coated  tongue,  nausea,  tenderness 
over  the  epigastrium,  headache,  quickened  pulse,  slight  fever, 
and  slight  jaundice.  Soon  the  jaundice  deepens;  the  pulse 
becomes  slow;  the  headache  increases;  and  there  is  persistent 
insomnia.  Within  a  very  short  period  appear  delirium,  fever, 
rapid  pulse,  abdominal  pain,  "coffee  grounds"  vomit,  tarr}' 
stools,  hemorrhages  from  the  mucous  membranes  and  into  the 
skin,  convulsions,  drowsiness,  coma,  and  death.  The  affection 
seldom  lasts  more  than  a  week  but  in  some  cases  is  prolonged 
to  two  or  three  weeks. 

The  liver  diminishes  rapidly  in  size  as  may  be  shown  by  pal- 
pation and  percussion  and  there  is 'pitting  on  pressure  in  the 
epigastric  region.  The  spleen  is  enlarged;  obstinate  vomiting, 
intense  jaundice,  and  hemorrhages  may  occur.  The  urine  is 
scanty,  of  high  specific  gravity,  and  contains  albumin,  bile, 
bile-stained  fatty  casts,  renal  epithelium,  leucin  spheres, 
tyrosin  needles,  and  aromatic  oxyacids.  Urea  is  diminished 
and  may  be  absent. 

Prognosis. — The  disease  always  terminates  fatally.  Appar- 
ent recoveries  nearly  always  imply  erroneous  diagnosis.     - 

Treatment. — The  treatment  consists  entirely  in  combating 
the  symptoms  as  they  arise. 

CIRRHOSIS    OF   THE    LIVER. 

Synonyms. — Interstitial  hepatitis;  hobnailed  liver;  gin- 
drinker's  liver. 

Definition. — An  inflammation  of  the  intervening  connective 
tissue  of  the  liver,  chronic  in  its  progress,  resulting  in  an  indura- 
20 


3o6  CIRRHOSIS    OF    THE   LIVER. 

tion  or  hardening  of  the  organ,  and  an  atrophy  of  the  secreting 
cells;  characterized  by  gastrointestinal  catarrh,  emaciation, 
slight  jaundice,  and  ascites. 

Causes. — The  prolonged  use  of  alcoholic  stimulants,  gin, 
whiskey,  beer,  or  porter  is  perhaps  the  most  common  cause.  It 
may  also  be  due  to  malaria,  syphilis,  passive  congestion,  and 
irritation  of  the  gall-ducts.  The  cause  may  be  undiscoverable. 
It  usually  occurs  in  men  past  thirty-five  years  of  age.  The 
uric  acid  diathesis  may  be  a  causal  factor. 

Pathologic  Anatomy. — Two  varieties  of  the  affection  are  rec- 
ognized,  atrophic  cirrhosis  and  hypertrophic  cirrhosis. 

Atrophic  cirrhosis  begins  with  hyperemia  of  the  connective 
tissue  (Glisson's  capsule)  and  enlargement  of  the  liver  results 
from  the  development  of  brownish-red  connective-tissue 
elements.  The  hypertrophied  connective  tissue  presses  upon 
the  hepatic  cells  causing  them  to  undergo  fatty  degeneration. 
As  this  process  advances  the  organ  becomes  reduced  in  size 
and  more  dense,  and  its  surface  is  covered  with  numerous  small 
nodules  ("hobnails").  The  hepatic  and  portal  circulation 
is  obstructed  from  obliteration  of  their  respective  radicles. 
The  changes  in  the  hepatic  structure  interfere  with  the  venous 
circulation  of  all  the  abdominal  viscera,  resulting  in  venous  con- 
gestion of  the  stomach,  pancreas,  intestines,  and  peritoneum, 
and  enlargement  of  the  abdominal  veins.  The  hepatic  perit- 
oneum is  thickened  and  opaque,  and  adhesions  are  formed 
between  the  liver  and  diaphragm,  gall-bladder  and  stomach. 
On  section  of  the  liver,  firm  fibrous  tissue  is  found  in  abundance 
distributed  between  the  lobules. 

Hypertrophic  cirrhosis  occurs  in  younger  individuals  than  the 
preceding  and  does  not  seem  to  be  dependent  upon  alcohol  for 
its  production.  The  organ  is  yellowish  in  color  and  remains 
enormously  enlarged  throughout  its  entire  course.  The  newly- 
formed  connective  tissue  shows  very  little  tendency  toward 
contraction  or  toward  compression  of  any  of  the  branches 
of  the  portal  vein.  The  connective  tissue  is  developed  to  a 
greater  extent  within  the  lobules  and  thus  produces  obstruction 
of  the   biliary   channels   and   consequent  jaundice.      By   some 


CIRRHOSIS    OF    THE   LIVER.  307 

observers  it  is  claimed  that  there  is  a  new  formation  of  biliary- 
capillaries  and  a  proliferation  of  the  liver  cells. 

The  main  thing  to  remember  is  that  cirrhosis  is  character- 
ized by  an  increased  growth  of  fibrous  tissue  in  the  capsule 
of  Glisson  and  of  connective  tissue  in  the  liver  substance;  by 
portal  obstruction;  by  increased  blood  pressure  in  the  hepatic 
arteries;  and  later  by  obstruction  of  the  biliary  ducts,  and 
obliteration  of  the  liver  cells. 

Symptoms. — All  the  manifestations  of  hepatic  cirrhosis  are 
due  to  the  obstruction  to  the  portal  circulation  which  it  induces. 
Persistent  gastrointestinal  catarrh  attended  by  anorexia,  fetor 
of  the  breath,  nausea,  epigastric  distention  and  distress, 
flatulence,  and  constipation  are  present.  When  accompanied 
by  attacks  of  jaundice  in  a  drinking  man,  the  early  stage  of 
cirrhosis  of  the  liver  should  be  suspected.  As  the  condition 
progresses  and  the  obstruction  becomes  more  marked,  hemor- 
rhages from  the  nose,  esophagus,  stomach,  or  intestine,  hemor- 
rhoids, dilatation  of  the  superficial  abdominal  veins  forming 
the  ''caput  meduscB,"  ascites,  enlargement  of  the  spleen,  and 
swelling  and  edema  of  the  feet  occur.  The  condition  is  afebrile, 
and  emaciation,  localized  abdominal  pain,  and  sometimes 
jaundice  are  present. 

In  atrophic  cirrhosis  the  liver  dullness  is  enlarged  at  first,  but 
later  becomes  markedly  lessened.  Splenic  dullness  is  enlarged. 
The  skin  has  a  muddy  appearance  and  there  is  gradual  emacia- 
tion. The  symptoms  continue  from  two  to  four  year.s,  termin- 
ating fatally  in  about  one  year  after  the  dropsy  makes  its  appear- 
ance. The  urine  is  scanty,  high-colored,  of  increased  density, 
and  is  loaded  with  urates.  The  quantity  of  urea  is  diminished, 
and  ■  blood  and  bile-pigment  may  be  present.  The  ending  of 
the  affection  is  marked  by  drowsiness,  delirium,  convulsions, 
and  coma,  death  resulting  from  toxemia,  exhaustion,  hemor- 
rhage, or  similar  conditions. 

In  hypertrophic  cirrhosis,  jaundice  is  an  early  and  persistent 
symptom.  Congestion  of  the  digestive  tract,  enlargement  of 
the  spleen,  hemorrhoids,  and  ascites  are  absent  or  present  only 
in  mild  degrees.     The  liver  is  permanently  enlarged,  smooth, 


3o8 


CIRRHOSIS    OF    THE    LIVER. 


tender,  and  the  seat  of  paroxysms  of  pain.  The  urine  is  bile- 
stained  and  the  percentage  of  urea  is  normal.  Blood  is  absent. 
The  feces  may  be  devoid  of  bile-pigment  or  may  be  normal. 
The  red  blood  cells  are  diminished  about  one  half,  and  there  is 
a  relative  increase  in  the  leukocytes.  This  form  of  the  affection 
is  more  rapid  than  the  preceding,  terminating  with  acute 
toxemic  symptoms  in  death,  usually  in  one  or  two  years. 

Diagnosis. — The  characteristics  of  hepatic  cirrhosis  are  the 
history,  area  of  liver  dullness,  symptoms  of  portal  obstruction, 
jaundice,  and  the  course  and  termination.  The  distinction 
between  the  two  varieties  is  well  given  by  Thayer  in  the  follow- 
ing table,  which  may  be  useful  to  students : 


Hypertrophic    cirrhosis. 


Atrophic  cirrhosis. 


Synonyms.  Charcot's;  hypertro- 
phic; unilobular;  hepatogenous; 
biliary. 

Jaundice.  Early  and  marked,  bile 
often  absent  from  feces. 

Ascites.      Late  and  unimportant.  .  . 

Spleen.  Enlarged  early  and 
markedly. 

Alifnentary  hetnorrhage,  piles.  Not 
common. 

Liver.  Large,  smooth,  mottled  , 
green. 

New  fibrous  tissue.  In  fine  lines  and 
strands  between  acini  and  cells, 
involving  all  parts  equally. 


Laennec's;  atrophic;  multi- 
lobular; hematogenous;  hob- 
nail liver. 

Late  and  slight,  bile  usually 
present. 

Maybe  early;  often  enormous. 

Late  and  less. 

Common. 

Small,   rough,    pale   or   yellow. 

In  broad  bands,  making  promi- 
nent islands  in  which  the  sin- 
gle acinus  may  appear  nearly 
normal;  distributed  irregu- 
larly. 


Atrophy  of  the  liver,  or  the  nutmeg  liver,  is  almost  always  con- 
founded with  cirrhosis ;  the  former  occurs  most  commonly  with 
obstructive  diseases  of  the  heart  and  lungs,  and  the  surface  of 
the  organ  is  not  nodulated,  nor  is  there  a  history  of  alcoholism. 


AMYLOID    LIVER.  309 

Cancer  and  tubercle  of  the  peritoneum  have  many  symptoms 
akin  to  cirrhosis.  The  points  of  differentiation  are,  great  ten- 
derness over  abdomen,  rapidly-developed  ascites,  rapid  decline 
in  strength  and  flesh,  absence  of  jaundice,  absence  of  long- 
continued  dyspepsia,  absence  of  hepatic  changes  on  percussion, 
and  the  presence  of  tubercle  or  cancer  deposits  in  other  organs. 
(See  table  on  page  314.) 

Prognosis. — The  outlook  is  unfavorable  and  while  many 
cases  have  a  very  long  course,  the  disease  ultimately  has  a 
fatal  termination. 

Treatment. — The  diet  should  be  restricted  to  milk  and  similar 
unirritating  food.  Fatty  and  saccharine  substances  should  be 
eliminated.  Alcoholic  individuals  should  be  advised  to  cease 
drinking.  The  gastrointestinal  catarrh  should  receive  symp- 
tomatic treatment.  Bichlorid  of  mercury,  gr.  1/60  to  1/32 
(0.002  gm.),  gold  and  sodium  chlorid,  gr.  1/20  (0.003  gm.), 
sodium  phosphate,  oss  to  i  (2  to  4  gm.),  and  potassium  iodid, 
gr.  X  (0.6  gm.),  three  times  daily,  are  highly  recommended. 
The  portal  congestion  is  best  relieved  by  salines,  such  as  Hun- 
yadi,  Saratoga,  Friedrichshall,  or  Carlsbad  waters,  and  Ro- 
chelle  or  Epsom  salts.  The  abdominal  dropsy  or  ascites  will 
require  the  administration  of  saline  purgatives  and  diuretics. 
A  half  ounce  of  a  concentrated  solution  of  magnesium  sulphate 
taken  daily  before  breakfast  is  of  value,  as  is  also  the  pill  con- 
taining I  gr.  each  of  calomel,  digitalis,  and  squill  when  given 
after  each  meal.  Acetate  of  potassium  may  also  be  used. 
Tapping  is  necessary  when  these  measures  fail. 

Surgical  treatment,  with  a  view  to  establishing  an  anastomosis 
between  the  portal  and  systemic  circulation,  has  been  employed ; 
but  it  should  never  be  considered  in  the  presence  of  complicat- 
ing renal  or  cardiac  disease. 

AMYLOID  LIVER. 

Synonyms. — Waxy  liver;  lardaceous  liver;  albuminoid  liver. 

Definition. — A  peculiar  infiltration  into,  or  a  degeneration  of, 

the  structure  of  the  liver,  from  the  deposit  of  an  albuminoid  ma- 


3IO  AMYLOID   LIVER. 

terial  which  has  been  term.ed.  amyloid,  from  its  superficial  re- 
semblance to  starch  granules. 

'  Causes. — The  principal  cause  is  prolonged  suppuration,  espe- 
cially of  bones.  It  is  seen  in  coxalgia,  pulmonary  tuberculosis, 
syphilis,  rachitis,  cancer,  leukemia,  and  certain  infectious 
diseases. 

Pathologic  Anatomy. — The  liver  is  uniformly  enlarged  and 
its  surface  presents  a  pale,  glistening  appearance.  It  has  a 
doughy  consistency,  and  its  edges  are  blunt.  The  surface  of 
a  cut  section  is  whitish,  anemic,  and  homogeneous.  The 
deposit  begins  in  the  arterioles  and  capillaries  and  spreads  to 
the  fibrous  tissue  and  parenchyma.  The  other  viscera  become 
ultimately  affected  by  the  degenerative  change. 

The  reaction  with  iodin  and  sulphuric  acid  affords  a  certain 
test  for  the  amyloid  or  albuminoid  deposits.  After  further 
cleansing,  brush  over  the  parts  a  solution  of  iodin  with  iodid 
of  potassium  in  water,  when  they  will  assume  a  mahogany  color, 
and  if  diluted  sulphuric  acid  be  added,  a  violet  or  bluish  tint 
is  produced. 

It  may  also  be  detected  by  adding  a  i  per  cent,  solution  of 
anilin  violet,  which  strikes  a  pink  color  with  the  amyloid  ma- 
terial, while  the  unaffected  tissues  are  plain  blue. 

Symptoms. — There  are  no  characteristic  manifestations, 
except j^ the  enlargement  of  the  liver.  Hepatic  dullness  is 
increased  and  there  is  prominence  of  the  hepatic  area.  Pain 
is  absent.  The  spleen  and  kidneys  are  enlarged  and  the  urine 
is  increased  in  amount,  pale,  albuminous,  and  contains  amyloid 
casts  when  the  kidneys  are  involved  by  the  amyloid  change. 
Disorders  of  digestion,  diarrhea,  emaciation,  and  anemia  are 
common.     Jaundice  and  ascites  are  infrequent. 

Diagnosis. — Leukemia  is  also  characterized  by  uniform  en- 
largement of  the  liver  and  spleen,  but  the  history,  the  examina- 
tion of  the  blood,  and  the  presence  or  absence  of  amyloid  casts  in 
the  urine  will  aid  in  making  the  diagnosis. 

Prognosis. — The  progress  of  the  affection  may  be  retarded 
and  the  symptoms  relieved  if  the  underlying  cause  can  be  re- 
moved, otherwise  the  prognosis  is  unfavorable. 


HYDATID    CYST    OF    THE    LIVER.  3II 

Treatment. — The  focus  of  suppuration,  which  induces  the 
condition,  should  receive  prompt  surgical  treatment.  Tonics, 
.such  as  iron,  syrup  of  the  lactophosphate  of  calcium,  cod-liver 
oil,  quinin,  etc.,  should  be  administered  over  a  long  period.  Da 
Costa  recommends  ammonium  chlorid,  gr.  x  to  xx  (0.6  to 
1.3  gm.),  three  times  daily  for  several  weeks,  after  which  it  is 
replaced  by  the  syrup  of  the  iodid  of  iron,  beginning  with  nxx 
(0.6  c.c.)  and  increasing  it  to  oi  (4  c.c),  for  a  similar  [period, 
when  the  first  named  drug  is  again  employed. 


HYDATID  CYST  OF  THE  LIVER. 

Synonym. — Echinococcus  of  the  liver. 

Definition. — A  cystic  condition  of  the  liver,  due  to  the  in- 
vasion and  subsequent  development  of  the  embryos  of  the 
Tmnia  echinococcus ,  an  intestinal  parasite  found  in  dogs,  wolves, 
and  jackals  in  Iceland,  Australia,  and  portions  of  Europe.  It  is 
rare  in  this  country,  but  in  regions  where  the  relation  of  men  and 
dogs  is  more  intimate,  it  is  rather  common.  (See  page  290.) 
The  ova  are  accidently  ingested  with  the  food  and  drink  of  men, 
and  on  being  liberated  in  the  stomach  and  intestines  the 
larvae  find  their  way  into  the  portal  circulation,  and  thus  reach 
the  liver.  Here  they  become  lodged  and  loosen  their  hooklets, 
developing  into  a  cyst.  The  cyst  wall  has  two  layers,  the  inner 
of  which  is  the  germinal  layer  from  which  daughter  cysts  are 
developed.  The  attendant  irritation  gives  rise  to  the  formation 
of  an  additional  capsule  of  connective  tissue.  The  contents  of 
the  cyst  include  a  clear  nonalbuminous  fluid  of  low  specific 
gravity  rich  in  chlorids,  larvae,  hooklets  and  daughter  cysts. 
The  cyst  grows  slowly,  and  on  the  death  of  the  parasite  it 
may  undergo  inspissation  and  calcification  or  suppuration. 

Symptoms. — Unless  the  cyst  is  large  there  are  no  symptoms 
as  a  rule.  The  liver  is  then  irregularly  enlarged  and  there  is  a 
sense  of  fullness  in  the  hepatic  region.  Fluctuation  may  be 
detected  in  some  cases.  If  the  cyst  is  near  the  surface,  the 
placing  of  one  hand  over  the  tumor  and  tapping  it  lightly  with 


312  SYPHILIS    OF    THE    LIVER. 

the  fingers  of-  the  other  hand,  will  elicit  a  vibrating  or  trembling 
movement,  hydatid  thrill  or  fremitus.  Aspiration  should 
always  be  performed,  as  the  presence  of  a  few  booklets  in  the 
clear  fluid  withdrawn  is  diagnostic.  Jaundice,  pain,  dyspnea, 
fever,  and  pyemic  symptoms  may  occasionally  be  present. 
Suppuration  and  rupture  are  the  most  common  terminations, 
but  the  possibility  of  such  a  condition  remaining  quiescent, 
should  be  remembered. 

Diagnosis. — The  history,  slow  course,  smooth  elastic  fluctuat- 
ing tumor,  without  fever  or  emaciation,  and  the  aspirated  fluid 
and  booklets  will  distinguish  it  from  abscess,  cancer,  or  other 
conditions  with  which  it  may  be  confused. 

Prognosis. — In  the  absence  of  complications,  the  outlook  is 
guardedly  favorable,  otherwise  it  is  extremely  serious. 

Treatment. — There  is  no  medicinal  treatment.  Aspiration 
may  be  performed,  or  the  cyst  may  be  treated  as  an  abscess. 


SYPHILIS  OF  THE  LIVER. 

Syphilis  of  the  liver  may  be  congenital  or  acquired.  The 
congenital  form  may  be  either  a  diffused  cellular  infiltration 
which  produces  at  first  enlargement  and  hardening,  and  later 
atrophic  changes  and  irregularities,  or  a  circumscribed  lesion,  a 
gumma.  The  acquired  variety  includes  diffuse  interstitial 
hepatitis,  gumma,  amyloid  disease,  and  endarteritis. 

Symptoms. — Jaundice  in  the  course  of  syphilis  should  always 
indicate  subsequent  careful  attention  to  the  liver.  Frequently 
the  lesions  escape  detection ,  ante-mortem.  The  symptoms, 
when  present,  are  those  of  portal  obstruction  as  in  ordinary 
cirrhosis. 

Diagnosis. — This  is  extremely  difficult  and  depends  largely  on 
the  history  and  the  results  of  the  therapeutic  test. 

Treatment. — Antisyphilitic  treatment  should  be  promptly 
instituted  if  there  is  the  slightest  possibility  of  syphilis,  as  in 
the  early  cases  the  best  results  are  obtained. 


CARCINOMA    OF    THE    LIVER.  313 

CARCINOMA  OF  THE  LIVER. 

Synonym. — Hepatic  cancer. 

Definition. — A  peculiar  morbid  growth,  progressively  destroy- 
ing the  hepatic  tissue;  characterized  by  disorders  of  digestion, 
anemia,  emaciation,  jaundice,  and  ascites,  and  terminating 
in  death  of  the  patient. 

Causes. — It  may  arise  as  a  primary  growth,  but  it  is  more 
often  secondary  to  a  similar  affection  in  some  adjacent  or  remote 
portion  of  the  body.  It  usually  occurs  in  men  from  forty  to 
sixty  years  of  age,  and  seems  to  be  influenced  by  heredity, 
traumatism,  and  various  forms  of  irritation. 

Pathologic  Anatomy. — In  most  cases  the  growth  is  secondary, 
and  is  an  admixture  of  medullary  and  scirrhus  cancer.  It  arises 
from  the  lodgement  of  cancerous  emboli  in  the  portal  capillaries. 
These  emboli  proliferate,  and  cause  portal  obstruction  and  in- 
filtration of  the  liver  with  numerous  grayish-white  nodules, 
which,  when  superficial,  are  umbilicated.  The  liver  is  increased 
in  size.  The  hepatic  cells  atrophy,  and  the  branches  of  the 
hepatic  artery  enlarge  and  permeate  the  growth.  The  perit- 
oneum is  adherent,  cloudy,  and  thickened.  Primary  cancer  of 
the  liver  occurs  usually  as  a  solitary  growth,  but  may  be  nodu- 
lar and  accompanied  by  cirrhosis. 

Symptoms. — The  development  of  hepatic  cancer  is  preceded  by 
a  history  of  dyspepsia,  flatulency,  and  constipation.  Abdominal 
distress,  weight,  and  pain,  increased  on  pressure,  are  noticed.  In 
addition  there  are  jaundice,  ascites,  occasionally  intense 
hemorrhages,  emaciation,  feebleness,  anemia,  cold,  dry,  harsh 
skin,  pinched  features,  dejected  expression,  and  all  the  symptoms 
of  cachexia.  Fever  is  absent,  except  when  there  are  compli- 
cations, and  toward  the  termination  of  the  disease.  The 
hepatic  dullness  is  increased,  and  the  liver  is  indurated,  ir- 
regular, nodulated,  and  painful  on  palpation. 

Diagnosis. — The  age,  sex,  history  of  primary  growth,  usually 
in  stomach,  cachexia,  pain  and  tenderness  on  palpation,  and 
enlargement  and  nodulation  of  the  liver  are  the  distinguishing 
features  of  hepatic  cancer. 


314 


SARCOMA    OF    THE    LIVER. 


Sometimes  the  diagnosis  between  carcinoma  and  cirrhosis 
is  difficult;  the  following  table  (from  Wheeler  and  Jack)  may 
help: 


Carcinoma. 


Cirrhosis. 


1 .  Progress:     Always  rapid i . 

2.  Liver:      Is  large,  and  the  nodular!   2, 
character     developed     from    the 
first.  : 

3.  Pain:      "Well  marked 

4.  Ascites:     Often  absent \   4. 

5.  Jaundice:      Often    a     markedl    5. 
feature.  I 


Often  slow. 

Enlarged   at    first,    then 

smaller,    and   more   nodular 

as    atrophy    becomes    more 

marked. 

Not  marked. 

Usually  present. 

Not  till  late. 


Prognosis. — The  disease  always  terminates  in  death,  usually 
within  a  year  after  its  recognition. 

Treatment. — The  treatment  is  entirely  symptomatic.  Opium 
will  be  frequently  required  to  relieve  the  pain. 


SARCOMA  OF  THE  LIVER. 


Sarcoma  of  the  liver  is  nearly  always  secondary,  arising, 
usually,  as  a  metastatic  growth  from  melanotic  sarcoma  of  the 
eye.  It  is  multiple  in  most  cases,  and  is  said  never  to  be  at- 
tended by  ascites.  It  gives  rise  to  irregular  enlargement  of  the 
liver  and  a  host  of  symptoms  common  to  all  chronic  hepatic 
affections.  The  diagnosis  is  difficult  and  the  condition  termin- 
ates fatally. 


JAUNDICE.  315 

DISEASES  OF  THE  BILE  PASSAGES  AND  GALL- 
BLADDER. 

JAUNDICE. 

Synonym. — Icterus. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  bile-ducts  and  of  the  duodenum;  character- 
ized by  gastrointestinal  derangement,  yellowness  of  the  skin  and 
sclera,  itching  of  the  skin,  feverishness,  and  mental  depression. 

Causes. — Extension  of  gastrointestinal  inflammation,  such  as 
follows  a  debauch,  excesses  in  eating  and  drinking,  and  ex- 
posure, is  the  most  common  cause.  Atmospheric  changes, 
passive  congestion  of  the  liver,  and  the  infectious  fevers,  such 
as  pneumonia,  malaria,  relapsing  fever,  etc.,  are  less  frequent 
factors  in  its  production. 

Pathologic  Anatomy. — The  mucous  membrane  of  one  or  more 
of  the  bile-ducts,  or  of  the  duodenum,  becomes  hyperemic, 
swollen,  and  thickened,  from  an  effusion  of  serum  into  the  sub- 
mucous tissue;  the  result  of  this  condition  is  the  closure  of  the 
biliary  passages,  thereby  impeding  the  outward  flow  of  bile. 
The  bile  in  the  hepatic  ducts  being  retained  by  the  obstruction 
results  in  a  staining  of  the  liver  substance  and  an  absorption 
of  bile,  with  its  appearance  in  the  blood. 

Symptoms. — -The  affection  begins  with  epigastric  distress, 
coated  tongue,  impaired  appetite,  nausea,  with  perhaps  vomit- 
ing, and  looseness  of  the  bowels  and  slight  feverishness.  In 
from  three  to  five  days  the  eyes  become  yellow,  and  jaundice 
gradually  appears  over  the  whole  body;  the  feverishness  dis- 
appears, the  skin  becomes  harsh,  dry,  and  itchy,  the  bowels 
constipated,  the  stools  whitish  or  clay-colored,  accompanied 
with  much  flatus  and  colicky  pains;  the  urine  heavy  and  dark, 
loaded  with  urates  and  containing  biliary  elements.  A  few 
drops  of  the  urine  placed  on  a  whitish  surface,  and  a  drop  or 
two  of  nitric  acid  made  to  flow  against  it,  will  exhibit  the 
following  "play  of  colors":  a  greenish  tint,  from  the  conversion 
of  bilirubin  into  biliverdin,  quickly  followed  by  blue,  violet, 
red,  and  yellow,  or  brown.     When  the  jaundice  is  complete, 


3l6  JAUNDICE. 

the  surface  is  cold,  the  heart's  action  slow,  the  mind  torpid 
and  greatly  depressed,  and  pain  or  tenderness  on  pressure  over 
the  hepatic  region. 

The  symptoms  subside  within  a  few  days  after  the  jaundice 
appears,  but  the  depression,  discoloration,  and  condition  of  the 
bowels  persist  for  one  or  two  weeks. 

Diagnosis. — Catarrhal  jaundice  may  be  recognized  by  its  acute 
course,  the  history,  the  mild  symptoms,  the  age,  and  the  termin- 
ation. Jaundice  is  readily  detected  by  examination  of  the  mu- 
cous membranes  of  the  eyes  and  mouth,  the  clay-colored  stools, 
and  by  the  reaction  of  the  urine  to  nitric  acid.  The  discoloration 
of  the  skin  alone  is  not  positive. 

When  jaundice  is  induced  by  obstruction  to  the  outflow  of 
bile  other  than  that  produced  by  inflammation,  such  as  arises 
from  stricture  of  the  common  duct,  tumors  of  the  abdominal 
viscera,  foreign  bodies  such  as  gall-stones  and  parasites,  fecal 
accumulations,  spasms  of  the  bile  ducts  due  to  emotion,  etc., 
the  symptoms  of  these  different  affections  will  be  found  as- 
sociated with  the  icteroid  manifestations. 

Icterus  neonatorum  is  the  variety  that  occurs  in  children,  and 
may  be  due  to  a  patulous  ductus  venosus  which  allows  the  portal 
blood,  rich  in  bile,  to  enter  the  circulation;  or  to  some  morbid 
condition  of  the  liver  or  bile-duct  which  causes  insuperable 
obstruction,  such  as  septic  phlebitis  of  the  umbilical  vein,  or 
congenital  syphilitic  hepatitis.  In  the  first  variety,  recovery 
is  the  rule  within  a  few  days,  to  a  week  or  more,  but  in  the  second 
the  termination  is  usually  fatal. 

Non-obstructive  or  hematogenous  jaundice  is  unassociated 
with  inflammatory  changes  in  the  bile-ducts,  and  arises  from 
disintegration  of  the  blood  or  hemolysis.  It  may  be  caused  by 
poisons,  suchasnitrobenzol,  chlorates,  snake-venom,  chloroform, 
phosphorus,  etc.,  yellow  fever,  relapsing  fever,  bilious  fever, 
pernicious  anemia,  pyemia,  typhoid  fever,  acute  yellow  atrophy 
of  the  liver,  and  similar  conditions.  It  differs  from  catarrhal 
jaundice  in  its  history,  the  absence  of  clay-colored  stools,  and 
less  staining  of  the  urine. 

Treatment. — The  patient  should  be  placed  at  rest  in  bed  and 


15 

gm. 

15 

c.c. 

4 

c.c. 

6o 

c.c. 

ad  i8o 

c.c. 

CHOLELITHIASIS.  317 

the  diet  restricted  to  milk  and  lime-water,  broths,  eggs,  lean 
meats,  etc.,  care  being  taken  to  eliminate  all  starchy,  fatty,  or 
saccharine  substances.  Calomel,  gr.  1/4  (0.016  gm.),  with 
sodium  bicarbonate,  gr.  iii  (0.2  gm.),  should  be  then  given 
every  two  hours  until  twelve  doses  are  taken,  followed  by 
Hunyadi  water  or  the  following: 

I^.      Sodii  bicarb 3iv 

Tinct.  nucis  vom 3iv 

Tinct.  capsici 3j 

Tinct.  rhei 5ij 

Inf.  gent.  comp. .  .q.  s.  ad    §vj 
M.  S. — Dessertspoonful  every  four  or  five  hours,  in  water. 

Sodium  phosphate,  oi  (4  gm.),  may  also  be  given,  well 
diluted,  every  four  hours.  The  dry,  itching  skin  may  be 
relieved  by  diaphoresis,  a  hot  bath  containing  potassium 
carbonate  night  and  morning,  or  a  weak  carbolic  acid  solution. 
If  insomnia  is  present  potassum  bromid,  gr.  xxx  (2  gm.),  may 
be  administered.  Diuretics  are  indicated  if  the  urine  continues 
scanty,  preference  being  given  to  the  alkaline  waters,  potassium 
bitartrate  lemonade,  and  spirit  of  nitrous  ether,  n^x  to  xx 
(0.6  to  1.3  c.c).  In  cases  in  which  the  constipation  persists, 
aloes,  podophyllum,  colocynth,  and  other  cholagogues  should 
be  employed.  Irrigation  of  the  colon  once  daily  with  cold 
water,  gradually  increasing  the  temperature,  is  often  very 
effective.  During  convalescence,  and  when  the  condition  tends 
to  become  chronic,  the  following  is  of  great  benefit: 

I^.      Strychninae  sulph gr.  ss  .03  gm. 

Acid,     nitrohydrochloric 

dil 3iv  15 .        c.c. 

Tinct.  gentian,  comp...      Siiss  75.        c.c. 

M.  S. — Teaspoonful  after  meals,  well  diluted. 

CHOLELITHIASIS. 

Synonyms. — Hepatic  calculi;  gall-stones;  hepatic  colic; biliary 
calculi. 

Definition. — Concretions  originating  in  the  gall-bladder  or 
biliary  ducts,  derived  partly  or  entirely  from  the  constituents  of 


3l8  CHOLELITHIASIS. 

bile.  Their  presence  is  generally  unrecognized  until  one  or 
more  attempt  to  pass  along  the  ducts,  when  an  attack  of  hepatic- 
colic  is  produced. 

Causes. — Gall-stones  result  from  the  precipitation  of  the 
crystallizable  cholesterin  and  its  combination  with  inspissated 
mucus  in  the  gall-bladder  or  ducts.  Bacteria  are  causal  factors 
in  that  they  induce  inflammatory  changes  in  the  gall-bladder 
in  consequence  of  which  cholesterin  and  lime  salts  are  excreted 
in  excess  and  deposited.  The  affection  is  most  common  in 
women  past  middle  life,  particularly  in  those  who  have  abdomi- 
nal tumors  or  have  borne  a  number  of  children.  Obesity, 
sedentary  habits,  excesses  in  eating  (particularly  of  saccharine 
and  starchy  foods)  and  drinking,  tight  lacing,  typhoid  fever, 
and  malignant  disease  of  the  stomach  and  liver  are  also  etiologic 
factors. 

Pathology. —  Biliary  calculi  vary  greatly  in  size  and  number; 
several  hundred  have  been  found  in  the  gall-bladder.  As  a 
rule,  the  stone  is  brown  and  spherical,  oval,  or  polygonal. 
The  shape  varies  according  to  the  manner  in  which  the  calculi 
are  packed  together  during  their  formation.  Cholesterin  is  the 
chief  constituent,  but  bile-pigment  and  lime  salts  may  also  be 
present.  On  section,  the  calculus  shows  the  manner  of  its 
formation  by  the  concentrically  arranged  layers  of  different 
color.  Commonly  several  stones  exist,  and  they  are  generally 
found  in  the  gall-bladder  or  cystic  duct,  but  may  very  rarely 
be  found  in  the  liver  or  hepatic  duct. 

Symptoms. — The  manifestations  of  biliary  calculi  vary 
according  to  the  course  of  the  affection.  While  they  remain 
quiescent  in  the  gall-bladder  they  may  occasion  but  very  little 
discomfort  and  often  remain  undetected  for  a  long  period. 
Often  they  induce  expulsive  efforts  of  the  gall-bladder  by  their 
irritation,  and  may  be  pushed  on  into  the  bowel,  into  the  cystic 
duct,  or  into  the  common  duct.  This  event  is  always  marked 
by  hepatic  or  biliary  colic.  If  the  calculi  pass  completely  into 
the  bowel  and  are  not  too  large  they  may  appear  in  the  stools, 
more  often  they  slip  back  into  the  gall-bladder  and  the  attack 
subsides  to  recur  at  a  later  period.     If  they  pass  into  the  cystic 


CHOLELITHLA.SIS.  3^9 

or  common  duct,  and  neither  find  a  free  exit  nor  slip  back  into 
the  gall-bladder,  impaction,  perforation,  peritonitis,  suppurative 
cholecystitis,  suppurative  angiocholitis,  and  hepatic  abscess  are 
the  possible  terminations.  Irritation  of  the  gall-bladder  by 
gall-stones  is  believed  by  some  observers  to  ultimately  induce 
malignant  disease  of  the  biliary  passages. 

Hepatic  colic  commences  suddenly  at  the  moment  a  calculus 
passes  from  the  gall-bladder  into  the  cystic  duct  with  piercing, 
agonizing  pain,  which  begins  over  the  gall-bladder  and  spreads 
over  the  abdomen  to  the  chest  and  right  shoulder.  Tenderness 
and  rigidity  are  present  over  the  gall-bladder  and  also  extend 
over  the  abdomen.  Nausea,  vomiting,  a  small  feeble  pulse, 
cool  skin,  pale  distorted  anxious  expression,  fainting,  spas- 
modic trembling,  chills,  moderate  fever,  and  sometimes  con- 
vulsions accompany  the  attack.  The  paroxysm  lasts  from 
an  hour  to  two  or  more  days,  with  remissions  until  the  calculus 
reaches  the  duodenum,  when  the  pain  suddenly  ceases.  When 
the  stone  is  obstructed  in  its  passage  jaundice  results. 

Obstruction  of  the  cystic  duct  by  an  impacted  gall-stone  may 
be  followed  by  very  few  symptoms,  and  jaundice  is  absent. 
It  may  give  rise  to  dropsy  or  atrophy  of  the  gall-bladder  or 
cholecystitis. 

Obstruction  of  the  common  duct  by  an  impacted  calculus  is 
characterized  by  persistent  jaundice,  paroxysmal  pain,  and 
ague-like  attacks  of  chills,  intermittent  fever,  and  sweats. 
Nausea  and  vomiting  may  be  present,  and  there  may  be  enlarge- 
ment of  the  liver  and  spleen.  The  stools  are  sometimes  bile- 
stained.  These  symptoms  may  continue  for  months  or  years, 
and  if  the  obstruction  is  not  relieved,  suppurative  cholangitis, 
perforation,  or  fibroid  induration,  dropsy,  or  atrophy  of  the 
gall-bladder  may  result. 

Diagnosis. — Hepatic  colic  may  be  mistaken  for  renal  colic, 
but  in  the  latter  affection  the  pain  begins  in  the  lumbar 
region  and  follows  the  line  of  the  ureters  into  the  genitals. 
The  urine  is  bloody  and  may  contain  the  stone.  Jaundice  is 
absent. 

Intestinal  colic  is  attended  by  diffuse  abdominal  pain  and 


3  2  O  CHOLELITHIASIS . 

distention.  Flatulence  is  present  and  on  its  discharge  the  pain 
is  relieved. 

Pleurisy  on  the  right  side  may  cause  some  confusion,  but  the 
friction  sound  and  the  limitation  of  breathing  with  sharp  pain  on 
inspiration  will  aid  in  making  a  distinction. 

Appendicitis  is  characterized  in  most  cases  by  pain,  tender- 
ness, and  rigidity  in  the  right  iliac  region,  and  by  the  absence  of 
jaundice  and  bile-stained  urine. 

Gastralgia  is  usually  attended  by  paroxysmal  pain  over  the 
region  of  the  stomach,  which  is  relieved  by  pressure  and  by 
taking  food. 

Gastric  ulcer  may  be  accompanied  by  paroxysmal  pain,  under 
which  circumstances  it  is  usually  induced  by  eating,  and  in 
addition  localized  epigastric  tenderness,  hematemesis,  and 
hyperacidity  are  present. 

Pseudo-biliary  colic  may  resemble  this  affection  very  closely, 
but  its  occurrence  in  neurotic  women,  and  the  absence  of  calculi 
in  the  stools,  should  be  remembered  in  making  a  diagnosis. 

Prognosis. — Uncomplicated  cases  terminate  in  recovery  as 
a  rule.  The  occurrence  of  ulceration,  suppuration,  or  perfora- 
tion, is  of  grave  significance. 

Treatment. — During  an  attack  of  hepatic  colic,  morphin 
gr.  1/4  and  atropin  gr.  1/150  should  be  administered  hypo- 
dermically  and  must  often  be  repeated ;  and  warm  fomentations 
should  be  applied  over  the  region  of  the  liver  and  gall-bladder. 
Chloroform  may  be  necessary  in  some  cases  to  relieve  the  pain. 
If  there  is  any  tendency  toward  collapse,  a  hot  bath  and  diffusi- 
ble stimulants  should  be  administered. 

Succeeding  the  attack  and  during  the  intervals,  the  diet 
should  be  carefully  regulated,  eliminating  all  fatty  and  saccharine 
substances  and  the  patient  should  be  instructed  to  avoid  all 
excesses  and  indulge  moderately  in  exercise.  Water-drinking 
should  be  encouraged,  and  when  possible  the  saline  mineral 
waters,  such  as  Carlsbad,  Vichy,  and  Saratoga  waters  should 
be  employed.  Sodium  bicarbonate  or  sodium  phosphate,  5i 
(4  gm.),  may  be  administered  well  diluted  before  meals.  When 
constipation  tends  to  exist,   Rochelle  or  Epsom  salt  should  be 


ACUTE    INFECTIOUS    CHOLECYSTITIS.  32  1 

given  regularly  to  overcome  it.  Ether,  turpentine,  and  sweet 
oil  have  been  recommended  as  solvents,  but  their  efficiency  in 
this  respect  is  very  doubtful.  The  succinate  of  sodium,  gr.  v 
(0.32  gm.),  administered  three  times  daily  is  accredited  with 
beneficial  properties  in  preventing  recurrences. 

Surgical  intervention  is  indicated  when  complications  threaten 
and  when  the  symptoms  are  so  intense  and  persistent  as  to 
endanger  the  patient's  vitality. 

ACUTE  INFECTIOUS  CHOLECYSTITIS. 

Definition. — Acute  inflammation  of  the  gall-bladder. 

Causes. — The  affection  is  always  due  to  infection  by  patho- 
genic bacteria,  especially  the  colon  bacillus  and  typhoid  bacillus. 
Occasionally  the  pneumococcus,  staphylococcus,  and  strepto- 
coccus are  the  exciting  causes.  It  may  follow  irritation  from 
gall-stones,  pneumonia,  or  typhoid  fever. 

Pathologic  Anatomy. — The  inflammation  may  be  of  varying 
grades.  In  mild  forms  the  exudate  is  mucoid  or  muco-purulent ; 
in  the  more  severe  forms  it  is  purulent  and  the  inflammation 
may  proceed  to  ulceration,  perforation,  or  gangrene.  There 
may  be  adhesions  between  the  gall-bladder  and  colon  or  omen- 
tum. In  rare  instances  the  gall-bladder  may  be  distended  with 
blood. 

Symptoms.— Pain  at  the  border  of  the  thorax  to  the  right  of 
the  median  line  is  invariably  present,  and  the  gall-bladder  is  en- 
larged and  tender.  Vomiting  is  common.  Fever  accompanies 
the  condition  and  jaundice  may  or  may  not  be  present.  In  the 
presence  of  pus  the  fever  becomes  irregular  and  attended  by 
chills  and  sweats,  and  an  examination  of  the  blood  will  show 
leukocytosis. 

Diagnosis. — The  features  of  this  affection  that  serve  to  dis- 
tinguish it  are  the  history,  the  preceding  affection,  and  the  loca- 
tion of  the  pain  and  circumscribed  tenderness.  The  presence 
of  a  tumor  in  the  region  of  the  gall-bladder  is  confirmatory. 

Prognosis. — Many  mild  catarrhal  cases  undoubtedly  termin- 
ate in  recovery  without  being  recognized.  Suppurative  cases 
21 


322  ACUTE    PANCREATITIS. 

are  unfavorable  and  tend  toward  a  fatal  termination.     Prompt 
surgical  intervention  offers  the  only  hope. 

Treatment. — The  symptoms  should  be  treated  as  they  arise 
on  general  therapeutic  principles.  A  skilled  surgeon  should  be 
called  in  as  soon  as  the  condition  is  detected. 


DISEASES  OF  THE  PANCREAS. 

ACUTE  PANCREATITIS. 

Definition. — An  acute  inflammation  of  the  pancreas  affecting, 
primarily  the  fibrous  and  fatty  interstitial  tissue. 

Causes. — It  is  a  rare  disease,  but  is  most  common  in  males 
after  forty-five  years  of  age  and  may  result  from  gastrointestinal 
disorders,  impaction  of  gall-stones,  traumatism,  infectious 
fevers,  and  local  bacterial  infection. 

Pathologic  Anatomy. — The  appearances  of  the  organ  differ 
somewhat  according  as  to  whether  the  termination  is  hemor- 
rhagic, gangrenous,  or  suppurative. 

In  the  hemorrhagic  for  fn  the  organ  is  enlarged  and  infiltrated 
with  blood  in  various  stages  of  decomposition,  and  scattered  be- 
tween these  hemorrhagic  foci  are  white  areas  of  fat-necrosis. 
Round  cells  and  red  blood  corpuscles  are  found  in  the  ducts  and 
acini,  and  bacteria  are  present  in  large  numbers.  The  extrav- 
asation of  blood  may  be  extensive,  involving  the  adjacent 
tissue  and  the  various  peritoneal  folds. 

The  gangrenous  form  is  a  later  stage  of  the  preceding.  The 
tip,  or  even  the  entire  organ,  is  converted  into  an  offensive,  soft, 
slate-colored  mass.  Partial  or  complete  sequestration  of  the 
gland,  in  the  small  omental  cavity,  may  result,  often  its  only 
attachment  being  a  few  threads.  Peritonitis  accompanies  it, 
and  fat-necrosis  may  be  present.  Thrombosis  of  the  splenic 
and  portal  veins  may  occur. 

The  suppurative  form  is  also  a  terminal  affection.  The  pan- 
creas is  enlarged  and  the  seat  of  numerous  small  abscesses  and 
intervening  hyperemic  areas.  Diffuse  suppuration  may  occur, 
or  in  chronic  cases  a  solitary  abscess  may  be  formed.      Localized 


CHRONIC    PANCREATITIS.  323 

peritonitis  is  present  in  many  cases.  Thrombosis  of  splenic 
and  portal  veins  may  also  occur. 

Symptoms. — The  onset  is  sudden  with  intense  abdominal 
pain  and  tenderness  in  the  epigastrium,  and  vomiting.  The 
upper  left  quadrant  of  the  abdomen  becomes  distended  and 
tympanitic,  and  the  temperature  is  slightly  above  or  below 
normal.  The  symptoms  of  collapse  soon  present  themselves 
and  the  patient  succumbs,  as  a  rule,  within  three  days.  The 
occurrence  of  chills,  fever,  marked  abdominal  distention,  tender- 
ness, and  tympany,  and  jaundice,  in  addition  indicates  a  ter- 
mination by  gangrene.  Suppuration  is  attended  by  irregular 
fever,  jaundice,  constipation,  and  prolongation  of  life  for  three 
or  four  weeks. 

Diagnosis. — This  must  be  made  from  the  symptoms  and 
their  suddenness,  especially  the  circumscribed  tympany. 
Intestinal  obstruction,  perforation  of  the  stomach,  acute  toxic 
gastritis,  and  biliary  colic  resemble  this  affection  in  many  of 
its  symptoms,  and  the  clinical  history  must  be  relied  upon  to  a 
great  extent  in  distinguishing  them. 

Prognosis. — The  disease  is  almost  always  fatal. 

Treatment. — Surgical  intervention  offers  the  only  hope,  as 
medicinal    measures    are    useless. 

CHRONIC  PANCREATITIS. 

Definition. — A  condition  in  which  there  is  interstitial  over- 
growth of  the  pancreas,  increasing  the  density  and  size  of  that 
organ  and  compressing  the  secreting  structure.  Pigmentary  de- 
posits may  be  present,  and  calculi  may  be  lodged  in  the  ducts. 

Causes. — In  rare  instances  it  follows  the  acute  form,  but  more 
frequently  it  is  due  to  arterial  sclerosis,  alcoholism,  syphilis,  ob- 
struction of  the  pancreatic  duct,  extension  from  gastrointestinal 
inflammation,     or    diabetes. 

Symptoms. — There  are  no  characteristic  symptoms.  Par- 
oxysmal pain,  abdominal  distention,  indigestion,  diarrhea, 
fatty  stools,  jaundice,  albuminuria,  and  glycosuria  may  be  pres- 
ent in  varying  combinations. 


324  CANCER  OF  THE  PANCREAS. 

Treatment. — There  is  no  special  treatment  unless  impacted 
gall-stones  are  detected  as  a  cause,  when  surgical  procedures 
will  be  found  very  valuable.  The  elimination  of  fats  and  starches 
from  the  diet  is  advised.  The  treatment  suggested  for  diabetes 
mellitus  is  applicable  to  this  condition.  The  course  is  very 
slow,  and  with  the  appearance  of  glycosuria,  the  outlook  be- 
comes proportionately  grave. 

CANCER  OF  THE  PANCREAS. 

Pancreatic  cancer  is  a  rare  condition.  The  growth,  as  a 
rule,  is  primary,  and  of  the  scirrhous  variety,  affecting  first  the 
head  of  the  organ.  It  is  most  common  in  males  past  forty 
years   of   age. 

Symptoms. — The  most  important  symptoms  are  the  tumor 
in  the  region  of  the  pancreas,  jaundice,  and  fatty  or  greasy 
stools.  Associated  with  these  are  usually  dull  epigastric  pain, 
indigestion,  weakness,  emaciation,  anemia,  and  cachexia.  As 
the  tumor  enlarges  and  emaciation  progresses,  the  aortic  pul- 
sation may  be  transmitted  to  it.  Ascites  may  result  from 
pressure  on  the  portal  vein.      Diabetes  mellitus  may  also  occur. 

Diagnosis. — The  location  of  the  tumor,  jaundice,  and  fatty 
stools  will  aid  greatly  in  distinguishing  this  affection  from 
pyloric  cancer,  with  which  it  may  sometimes  be  confused. 

Treatment. — The  treatment  is  symptomatic  and  very  unsat- 
isfactory,   as    all    cases   terminate    fatally. 

CYSTS  OF  THE  PANCREAS. 

Cystic  tumors  of  the  pancreas  are,  as  a  rule,  retention  cysts 
due  to  the  closure  of  the  duct  of  Wirsung,  by  concretions,  tu- 
mors, or  cicatrices,  but  they  may  result  from  encapsulation  of 
extravasated  blood,  echinococcus  disease,  or  malignant  tumors. 
Congenital   cysts    are   sometimes   encountered. 

Symptoms. — Fatty  stools  are  exceptional ;  but  they  may  be 
clay-colored  and  putrescent.  An  enlargement  may  be  ustially 
made  out  in  the  left  portion  of  the  epigastrium,  between  the 
costal  cartilages  and  the  median  line,  which  will  be  globular, 


PANCREATIC    CALCULI.  325 

resisting,  and  inelastic.  Aspiration  of  the  tumor  will  yield  a 
fluid  of  brown  or  chocolate  color,  which  is  capable  of  emul- 
sifying fats  and  converting  starch  into  sugar.  Abdominal 
pain,  digestive  disturbances,  and  emaciation  accompany  it. 
Treatment. — The  treatment  is  surgical  after  withdrawal  of 
the  characteristic  fluid.      The  outlook  is  guardedly  favorable. 

PANCREATIC  CALCULI. 

Calculi  in  the  pancreas  may  be  regarded  as  inspissated  part- 
icles of  altered  pancreatic  secretion,  around  which  concre- 
tions of  carbonate  and  phosphate  of  lime  occur.  They  are 
multiple  and  about  the  size  of  a  pea,  being  found  in  the  pan- 
creatic   duct    and    its    branches. 

Symptoms. — They  may  be  unattended  by  symptoms  or 
there  may  be  pancreatic  colic,  glycosuria,  fatty  stools,  and 
the  passage  of  calculi  by  the  bowel. 

Treatment. — Morphin  and  atropin  are  required  to  relieve 
the  pain.  Pilocarpin  has  been  advised  for  its  stimulant  effect 
on   pancreatic   secretion. 

THE  CAMMIDGE  REACTION. 

This  reaction  is  highly  suggestive  of  pancreatic  disease,  and 
if  taken  in  conjunction  with  the  clinical  evidence  may  be  of 
some  aid  in  diagnosing  inflammatory  destructive  lesions  of  the 
pancreas.  It  is  probably  not  pathognomonic,  and  its  technic 
is  far  from  simple.  For  the  benefit  of  those  who  are  capable 
of  performing  the  test  and  determining  its  value,  Greene's 
description  of  the  reaction  is  herewith  appended: 

"A  specimen  of  the  twenty-four  hours'  urine  is  filtered  free 
from  sugar  and  albumin  if  necessary  and  acidified  if  it  show 
an  alkaline  reaction.  To  20  c.c.  of  the  filtrate  one  adds  i  c.c. 
of  strong  HCl  (sp.  gr.  1.16)  and  boils  the  mixture  gently  for 
ten  minutes  on  a  sand-bath,  using  a  small  flask  with  a  long- 
stemmed  funnel  which  acts  as  a  condenser. 

"  It  is  then  cooled  in  a  stream  of  water  and  sufficient  dis- 
tilled   water   added    to    make   good   the   loss   by    evaporation. 


326  PERITONITIS. 

Four  gm.  of  lead  carbonate  are  then  slowly  added.  The 
flask  is  set  aside  for  a  few  minutes,  again  cooled,  and  the  con- 
tents are  repeatedly  filtered  until  clear.  Four  gm.  of  tribasic 
lead  acetate  are  added  to  filtrate  and  well  shaken,  and  repeated 
filtration  is  followed  by  the  addition  of  2  gm.  of  powdered 
sodium    sulphate. 

"  The  mixture  is  raised  to  the  boiling  point,  thoroughly 
cooled,  and  again  filtered.  To  10  c.c.  of  the  clear  filtrate  8  c.c. 
of  distilled  water  is  added  and  treated  with  phenylhydrazin 
hydrochlorate,  0.8  gm.  sodium  acetate,  2  gm.  and  i  c.c.  of 
50    per    cent,    acetic    acid. 

"  The  mixture  is  again  boiled  in  the  small  condensing  flask 
over  the  sand-bath  for  ten  minutes  and  filtered  hot  into  a  test- 
tube  provided  with  a  15  c.c.  mark.  Should  the  filtrate  be  less 
than  15  c.c,  hot  distilled  water  should  be  added. 

"  If  the  pancreas  he  diseased  a  light  yellow  flocculent  precipi- 
tate should  form  in  a  few  hours.  Under  the  microscope  the 
crystals  appear  as  long  yellow  '  flexible  and  hair-like  crystals 
arranged    in    sheaves.' 

"  They  melt  away  in  from  ten  to  fifteen  seconds  if  irrigated 
with  T^T,  per  cent,  sulphuric  acid." 


DISEASES  OF  THE  PERITONEUM. 

PERITONITIS. 

Synonym. — Inflammation    of    the    peritoneum. 

Definition. — A  fibrinous  inflammation  of  the  peritoneum, 
either  acute  or  chronic,  characterized  by  fever,  intense  pain, 
tenderness,  tympanites,  vomiting,  and  prostration.  It  may 
be  limited  to  a  part,  local,  or  it  may  involve  the  entire  mem- 
brane,   general,  peritonitis. 

Causes. — The  acute  variety  arises  from  bacterial  infection 
and  may  follow  exposure  to  intense  cold,  protracted  irritation 
of  the  abdomen  by  blisters,  traumatism,  penetrating  wounds 
of  the  abdomen,  inflammation  or  perforation  of  the  stomach, 


PERITONITIS.  327 

intestines,  gall-  or  urinary-bladder,  vermiform  appendix,  or 
the  surrounding  parts,  inflammation  of  the  pelvic  viscera, 
pyemia,  septicemia,  erysipelas,  hernia,  pleurisy,  articular 
rheumatism,     and    nephritis. 

The  organisms  found  are  the  Staphylococcus  pyogenes  aureus 
or  albus,  Streptococcus  pyogenes,  Bacteriu^n  coli  commune,  and 
Tubercle    bacillus. 

The  chronic  variety  may  succeed  an  acute  attack,  but  is 
more  commonly  due  to  tuberculosis,  cancer,  nephritis,  or 
syphilis. 

Pathologic  Anatomy. — In  the  acute  form,  the  membrane  is 
hyperemic,  and  there  may  be  scattered  extravasations  of 
blood  from  rupture  of  the  distended  capillaries.  The  se- 
cretion is  arrested  and  the  peritoneum  becomes  dry,  lusterless, 
and  opaque.  The  inflammatory  exudate  may  be  serofibrinous, 
fibrinous,  or  purulent.  The  serous  or  serofibrinous  exudation  is 
productive  of  more  or  less  ascites.  As  the  fluid  is  absorbed 
the  fibrinous  portions  remain  behind  and  become  organized, 
giving  rise  to  adhesions  between  opposing  surfaces.  If  the 
inflammation  subsides  in  the  early  stage,  or  if  the  fibrin  is  in 
excess  from  the  beginning,  adhesions  form  without  ascites. 
These  adhesions  may  serve  to  wall  off  any  localized  purulent 
exudation,  thereby  converting  it  into  an  abscess.  The  inflam- 
matory process  may  be   diffused  or  circumscribed. 

In  the  chronic  form,  the  peritoneum  is  thickened  and  studded 
with  tuberculous  or  cancerous  nodules,  as  the  case  may  be. 
Adhesions  are  present  and  serve  to  mat  the  intestines  to- 
gether, and  to  disturb  the  relations  of  the  abdominal  viscera. 
There  is  a  varying  quantity  of  fluid  in  the  cavity,  which  is  al- 
buminous, but  may,  at  times,  be  bloody.  The  omentum  is 
greatly    thickened    and    shrunken. 

Symptoms. — Acute  peritonitis  is  manifested  by  a  sudden 
onset  with  a  chill,  fever,  101°  to  103°  F.,  and  a  tense  and  wiry 
pulse,  100°  to  140°  F.  There  is  present  also  intense  abdominal 
pain  and  tenderness.  The  patient  lies  motionless  on  the 
back,  with  the  legs  and  thighs  flexed.  The  expression  is 
anxious,   and  the   excruciating  cutting  or  boring  pain   causes 


328  PERITONITIS. 

the  features  to  appear  pinched.  The  abdomen  is  distended 
and  rigid  from  constipation,  effusion,  and  meteorism.  The 
breathing  is  shallow  and  thoracic,  and  the  diaphragm,  is  more 
or  less  fixed,  and  in  severe  cases  is  pushed  up  as  far  as  the  third 
or  fourth  rib,  causing  compression  of  the  lungs  and  displace- 
ment of  the  heart,  liver,  and  spleen.  Impairment  of  ap- 
petite, intense  thirst,  nausea,  vomiting,  and  hiccough  are  pres- 
ent. In  the  early  stage,  when  the  abdomen  is  distended 
with  gas,  percussion  will  yield  a  tympanitic  note,  but  later, 
as  the  exudate  is  poured  out,  dullness  will  be  obtained,  corre- 
sponding to  the  situation  of  the  exudate ;  small  and  fixed  if  cir- 
cumscribed, but  if  the  exudate  is  large  and  diffuse,  the  dullness 
will  be  movable.  The  course  of  the  disease  is  rapid,  especially 
in  severe  cases,  collapse  supervening,  being  indicated  by  sud- 
den normal  temperature  or  a  rapid  decline  in  the  existing  fever, 
cold  clammy  skin,  rapid,  feeble  pulse,  weakness,  and  the  Hip- 
pocratic  expression  (sunken  eyes,  collapsed  cheeks  and  tem- 
ples, pinched  nose,  and  drawn  upper  lip.)  The  urine  is  scanty 
and  contains  indican.  When  the  condition  is  produced  by 
extension,  it  begins  with  local  and  gradually  increasing  pain, 
tenderness,  and  rigidity,  rising  temperature,  tense  pulse, 
and  vomiting.  AVhen  it  follows  perforation  it  is  ushered  in 
with  severe  pain  and  all  the  symptoms  of  shock.  In  pur- 
ulent peritonitis,  hectic  phenomena  are  present.  In  ordinary 
cases,  peritonitis  runs  its  course  in  from  six  to  eight  days,  term- 
inating   in    collapse    or    a    protracted    convalescence. 

Chronic  peritonitis  is  usually  tubercular  in  origin,  and  is 
attended  by  irregular  chills,  fever,  and  sweats,  distended  ab- 
domen, constipation,  alternating  with  diarrhea,  diffused  ten- 
derness with  points  of  intensity  and  hardness,  colicky  paifis 
during  digestion,  rapid  emaciation,  anemia,  and  loss  of 
strength.  Usually  the  lower  portions  of  the  abdomen  yield  a 
dull  note  on  percussion  from  the  presence  of  fluid,  or  scattered 
but  fixed  points  of  dullness  showing  the  presence  of  encysted 
fluid.  Palpation  may  detect  a  friction  fremitus,  and  sometimes 
the  nodules  may  be  felt.  When  the  fluid  exudate  is  of  con- 
siderable quantity  fluctuation,  may  be  elicited. 


PERITONITIS.  329 

Diagnosis. — The  characteristics  of  acute  peritonitis  are  the 
sudden  onset,  intense  abdominal  pain,  tenderness,  rigidity, 
and  distention,  the  decubitus,  the  quick  wiry  pulse,  the  fever, 
the  constipation,  the  short  course,  and  the  Hippocratic  ex- 
pression. These  are  present  to  a  less  degree  in  chronic  per- 
itonitis, which  is  most  readily  distinguished  by  the  history 
and  the  results  of  physical  examination. 

Acute  gastritis  differs  from  peritonitis  in  having  a  history 
of  corrosive  poisoning  or  dietetic  indiscretion,  early  and  severe 
vomiting,  severe  pain  limited  to  the  stomach,  diarrhea  at 
times,  and  no  marked  abdominal  distention,  tenderness,  or 
rigidity. 

Acute  enteritis  has  localized  pain  and  tenderness,  and  diar- 
rhea is  almost  invariably  present. 

Rheumatism  of  the  abdominal  muscles  is  subacute;  rigidity, 
pain,  and  tenderness  are  present,  but  abdominal  distention, 
constipation,  and  marked  constitutional  symptoms  are  absent. 

Biliary  colic  is  attended  by  pain,  localized  in  most  cases  to 
the  hepatic  area;  rigidity  is  present  to  some  extent;  and  jaun- 
dice is  common.  The  pain,  tenderness,  rigidity,  and  disten- 
tion,   as   seen   in   peritonitis,    are   absent. 

Renal  colic  is  characterized  by  paroxysmal  pain,  which  be- 
gins posteriorly  and  follows  the  course  of  the  ureters,  and  is 
attended  by  altered  urinary  secretion  and  retraction  of  the 
testicle. 

Typhoid  fever  when  attended  by  marked  distention  and 
tenderness  may  resemble  peritonitis,  but  the  history,  temper- 
ature record,  Widal  test,  rose-colored  eruption,  and  diarrhea 
in  the  former  affection  will  distinguish  them.  The  occur- 
rence of  peritonitis,  secondary  to  perforation,  in  the  course 
of  typhoid  fever,  is  usually  announced  by  a  fall  of  temperature, 
marked  tympanites,  sudden  localized  pain,  quick  wiry  pulse, 
and    collapse. 

Intestinal  obstruction  is  marked  by  absolute  constipation 
and  stercoraceous  vomiting  and  less  abdominal  pain  and 
tenderness.  Rupture  of  an  obstructed  bowel  is  succeeded  by 
peritonitis. 


33©  PERITONITIS. 

Hysterical  abdomen  may  be  confused  with  peritonitis,  but 
its  occurrence  in  neurotic  women,  its  tendency  to  recur,  and 
the  absence  of  fever  and  the  characteristic  pulse  will  aid  ma- 
terially in  making  the  proper  diagnosis. 

Circumscribed  peritonitis  is  difficult  to  detect  and  requires 
for  its  recognition  a  careful  history  and  physical  examination, 
and  often  the  use  of  the  exploring  needle. 

Prognosis. — In  acute  peritonitis  of  septic  origin  the  ter- 
mination is  fatal  usually  within  a  week.  In  perforative 
cases  following  typhoid  fever,  Keen  has  shown  that  from  15 
to  30  per  cent,  recover  with  surgical  treatment  within  twenty- 
four  hours.  Localized  peritonitis  is  more  favorable;  an  abscess 
may  be  formed  which  may  rupture  spontaneously  or  be  evac- 
uated  at   a  later  period  by   a   surgeon. 

In  chronic  peritonitis  the  prognosis  is  unfavorable,  but  the 
duration  is  considerably  longer  than  the  acute  form.  Tuber- 
culous peritonitis,  when  properly  treated,  may  end  in  recovery 
or  at  least  suspension  of  the  disease-process  for  a  considerable 
period. 

Treatment. — The  surgeon  should  be  consulted  very  early 
in  the  acute  variety,  as  operation  offers  the  only  hope  in  many 
cases,  especially  those  due  to  perforation.  Counterirritation 
may  be  employed,  but  is  often  useless.  Morphin  and  atropin 
hypodermically  will  relieve  pain,  control  vomiting,  and 
lessen  peristalsis.  If  the  stomach  is  retentive,  ice,  milk  and 
lime-water,  champagne,  and  brandy  may  be  given.  Tur- 
pentine stupes  and  turpentine  enemas  are  frequently  beneficial. 
Belladonna  and  mercury  ointment  applied  locally  is  of 
value  at  times.  Strychnin,  quinin,  and  other  stimulants 
may  be  necessary.  In  non-perforative  cases,  saline  pur- 
gatives may  be  employed  in  concentrated  solutions,  admin- 
istering I  or  2  drams  of  Rochelle  or  Epsom  salt  every  two 
hours  until  there  is  free  bowel  movement.  In  circumscribed 
forms,  leeches,  blisters,  and  hot  applications  may  produce 
considerable  relief.  During  convalescence,  rest  in  bed,  nu- 
tritious diet,  moderate  stimulation,  and  the  following  are 
indicated : 


ASCITES.  331 

I^.     Potassii  iodidi gr.  v  to  x      .  3  to  .  6  gm. 

Ferri  pyrophosphat gr.  ij               .13  gm. 

Elix.  simpl 3ss              2  .  c.c. 

Aquae  destillatas.  .q.  s.  ad    oij         ad  8.  c.c. 
M.  S. — To  be  given  every  six  hours. 

Chronic  peritonitis  will  require  the  application  of  tincture 
of  iodin  to  the  abdomen,  rest  in  bed,  and  the  administration 
of  opium,  potassium  iodid,  cod-liver  oil,  and  stimulants. 
Surgical   treatment   is  necessary   in  many  cases. 

ASCITES. 

Synonyms. — Hydroperitoneum ;    abdominal    dropsy. 

Definition. — A  collection  of  serous  fluid  in  the  abdomen, 
or  more  correctly  in  the  peritoneal  cavity;  characterized  by 
a  distended  abdomen,  fluctuation,  dullness  on  percussion, 
displacement  of  viscera,  embarrassed  respiration,  plus  the 
symptoms  of  its  cause.  The  quantity  of  fluid  in  the  peritoneal 
sac  varies  from  a  few  ounces  to  many  gallons.  It  is  gener- 
ally of  a  straw  color,  or  at  times  greenish,  and  is  transparent, 
and  has  an  alkaline  reaction.  The  specific  gravity  is  from 
loio  to  1020.  When  blood  is  present  in  any  great  quantity 
it  points  to  cancer  as  a  cause.  The  peritoneum  becomes 
cloudy,  sodden,  and  thickened,  from  long  contact  with  the 
fluid. 

Causes. — It  may  be  a  part  of  a  general  dropsy  such  as  follows 
chronic  heart,  lung,  or  kidney  disease,  or  it  may  be  due  to 
chronic  peritonitis  or  mechanical  obstruction  of  the  portal 
circulation  from  hepatic  cirrhosis,  portal  thrombosis,  .or  ab- 
dominal   tumors.      It    may    accompany    intense    anemia. 

Symptoms. — The  onset  is  gradual  and  considerable  swell- 
ing of  the  abdomen  may  occur  before  the  disease  attracts 
attention.  The  umbilicus  is  forced  outward  and  constipa- 
tion, scanty  urination,  and  embarrassed  respiration  and  car- 
diac action  result  from  the  pressure  of  the  accumulated  fluid. 

Physicial   examination   reveals    on   inspection,    distention    of 


332 


ASCITES. 


the  abdomen,  the  surface  of  which  is  smooth  and  shining; 
if  the  distention  is  excessive,  "  silver  Hnes  "  Hke  those  observed 
in  pregnancy  will  be  seen ;  broadening  of  the  base  of  the  thorax ; 
bulging  of  the  flanks  when  the  dorsal  position  is  assumed; 
and  enlargement  of  the  superficial  veins.  On  palpation 
a  peculiar  wave-like  impulse  is  imparted  to  the  hand  lying  on 
the  side  of  the  abdomen,  while  gently  tapping  the  opposite  side. 
On  percussion  dullness  will  be  obtained  over  the  fluid,  which 
always  seeks  dependent  parts,  above  which  a  tympanitic  note 
will  be  heard.  The  dullness  is  movable,  changing  its  position 
with    the    changes    in    the    patient's    posture. 

Diagnosis. — Ascites  is  to  be  differentiated  chiefly  from 
ovarian  tumor  (or  cyst),  pregnancy,  and  distended  bladder. 
The  following  table  (based  on  one  in  Gould  and  Pyle's  Cyclo- 
pedia) will  aid  in  the  diagnosis : 


Ascites. 


Ovarian  tumors. 


Pregnancy. 


Distended  bladder. 


Frequently      a  s  s  o  - 
ciated  with  heart  or 
kidney  disease. 
Navel      often      pro- 
trudes;    caput     me- 
dusae present. 
Percussion  -note 
gives  dullness,  more 
perceptible  in  flanks 
or  lower  abdominal 
region,     where     the 
fluid  gravitates; 
movable  dullness. 
Tumor      develops 
from  below  and  ex- 
tends upward. 
No    signs     of     preg- 
nancy; and  health  is 
much  impaired. 
Growth    may   be 
rapid  or  not. 


1.  Heart    and    kid-     i. 
neys  normal. 

2.  Same  as  ascites.  '•    2. 


Same  as  ovarian  i 
tumor. 

Abdominal  veins 
enlarged. 


Percussion  -  note    3.   Same  as  ovarian 
gives    dullness  tumors ;  suppres- 

rather   high    up;  sion  of  menses, 

dullness    not 
movable.  I 


Tumor   develops 
to  right  or  left  of 
median  line. 
Same  as  ascites. 


6.   Slow  growth. 


4.  Enlargement  de- 
velops in  area  of! 
uterus. 

5.  Signs  of  preg-l 
nancy;  he  a  1  thj 
normal. 

6.  Grows  at  a  uni-j 
form  and  definite! 
rate.  | 


Heart  normal ; 
urine  suppressed 

Abdominal  veins 
normal. 

Dullness  immov- 
able;  catheter 
confirms  d  i  a  g  - 
nosis. 


4.  Enlargement  de- 
velops in  region 
of  bladder. 

5.  Same  as  ascites. 


6. 


Tympanites  is  characterized  by  enormous  distention  of  the 
abdomen,    but    percussion    yields    universal    tympany. 

Chronic  peritonitis  may  be  differentiated  by  its  history, 
pain,  tenderness,  more  or  less  vomiting,  thickened  abdominal 
walls,   smaller  effusion  with  less  range  of  motion  due  to  ad- 


ASciTics.  333 

hesions,  smaller  area  of  dullness,  and  its  common  association 
with  tuberculosis  or  cancer. 

Prognosis. — In  the  common  form  due  to  organic  disease,  the 
prognosis  is  unfavorable,  for  while  the  dropsy  may  be  removed 
it  rapidly  returns.  In  peritoneal  cases  it  is  more  favorable, 
and  in  idiopathic  cases,  which  are  rare,  it  terminates  in  health 
within  a  few  weeks. 

Treatment. — The  first  indication  is  to  treat  the  cause  of  the 
ascites    and    the    second    to    remove    the    fluid. 

Three  modes  of  removing  the  fluid  present  themselves: 
first,  by  hydragogue  cathartics;  second,  diuretics  and  dia- 
phoretics, and  third,  tapping.  The  first  and  second  modes  may 
be  combined  as  follows: 

I^.     Pulv.  jalapae  comp 5  j  to  ij  4  .  to  8  .  gm. 

S. — In  water,  an  hour  before  breakfast. 

And 

I^.     Potassii  acetat gr.  xxx  2  .  gm. 

Spts.  aetheris  nitrosi tt^xv  i  .  c.c. 

Infus.  digitalis.  .  .  q.  s.  ad  f  oij  ad  8.  c.c. 
M.  S. — -Every  six  hours. 

Or,  instead  use  the  following: 

I^.      Hydrargyri  chlor.  mitis.    gr.  iij  .2       gm. 

Ext.  opii gr.  1/12  .005  gm. 

M.  S. — One  every  three  or  four  hours. 

If  these  fail,  as  they  certainly  will  after  a  time,  the  embarrassed 
respiration  and  cardiac  action  will  call  for  tapping,  which  may 
be  performed  with  the  trocar  or  the  aspirator.  The  tapping 
does  not  remove  the  cause,  and  the  fluid  often  rapidly  accu- 
mulates again.  In  performing  this  operation  the  patient 
should .  be  placed  in  a  semirecumbent  posture,  and  the  area 
selected  (usually  in  the  median  line  between  the  umbilicus  and 
the  symphysis)  should  be  anesthetized  by  ethyl  chlorid  or  a  mix- 
ture of  ice  and  salt.  After  the  aspirator  has  been  thrust  into 
the  abdomen,  the  trocar  portion  is  withdrawn  and  the  liquid 
flows    through    the    cannula.     Pressure    should    be    made    by 


334  THE    URINE. 

means  of  a  four-tailed  bandage  to  prevent  collapse.  When  the 
liquid  has  been  entirely  removed  the  instrument  is  withdrawn, 
the  opening  sealed,  and  a  rather  tight  abdominal  binder,  with  a 
pad  of  cotton  or  gauze  applied.  Collapse  should  be  watched 
for  and  carefully  guarded  against  during  this  procedure.  Be- 
fore tapping  always  examine  the  bladder,  using  the  catheter  if 
necessary  or  if  there  is  any  doubt. 


DISEASES  OF  THE  URINARY  ORGANS. 

THE  URINE. 

The  normal  quantity  of  urine  voided  varies  from  40  to  50 
ounces  (1200  to  1500  c.c.)  in  the  twenty-four  hours;  the  gwaw- 
tity  depends  upon  the  amount  of  liquids  ingested,  the  amount 
of  perspiration  secreted,  the  temperature  and  moisture  of 
the  surrounding  atmosphere,  increase  or  decrease  of  blood 
pressure,  and  the  presence  or  absence  of  certain  diseases, 
such    as    diabetes,  nephritis,  etc. 

Within  the  twenty-four  hours,  the  least  urine  is  passed 
during  the  night  or  in  the  early  morning,  the  greater  portion 
being  passed  during  the  course  of  the   day. 

An  increase  in  the  quantity  of  urine  excreted  is  termed 
polyuria;  it  may  be  transient  or  permanent.  Transient  pol- 
yuria follows  the  crisis  of  febrile  affections,  chilling  of  the 
skin,  the  administration  of  diuretics,  the  ingestion  of  large 
quantities  of  fluids,  and  similar  conditions;  while  permanent 
polyuria  results  from  diabetes  mellitus,  diabetes  insipidus, 
chronic  interstitial  nephritis,  and  amyloid  disease. 

A  diminution  in  the  urinary  secretion  is  termed  oliguria,  and 
may  be  due  to  draining  of  the  fluids  of  the  body  through  other 
channels,  as  in  perspiration  and  diarrhea,  congestion,  and  inflam- 
mation of  the  kidneys,  fever,  collapse,  hysteria,  or  mechanical 
obstruction  somewhere  in  the  genitourinary  tract.  When  com- 
plete it  is  termed  suppression  of  the  urine  or  anuria. 

The  normal  color  is  light  amber,  due  to  pigments,  chiefly 
urobilin   and   uroxanthin;    the   color   deepens   if^the   quantity 


THE    URINE. 


335 


voided  be  decreased,  and  vice  versa.  In  nearly  all  normal 
urine  a  cloud  of  mucus  forms  after  standing  a  short  time. 

The  normal  reaction  is  slightly  acid,  due  almost  entirely 
to  acid  sodium  phosphate  (NaHoPOJ;  the  acidity  is  not 
due  to  uric  or  hippuric  acids.  After  meals,  it  may  be  neutral 
or  even  alkaline. 

The  normal  specific  gravity  varies  from  1.015  to  1.025;  it 
is  low  when  an  increased  quantity  is  passed,  and  high  when 
the  quantity  is  diminished. 

The  total  solids  in  urine  may  be  approximately  obtained 
by  multiplying  the  last  two  figures  of  the  specific  gravity  by  2 
(Trapp's  co-efficient);  this  gives  the  number  of  grams  per 
liter.  Thus,  if  a  given  sample  of  urine  has  a  specific  gravity  of 
1. 015,  it  will  contain,  approximately,  15x2  =30  grams  per  liter; 
if  1500  c.c.  be  passed  in  twenty-four  hours,  the  solids  will  total 
30x1.5=45  grams. 

The  normal  odor  of  urine  is  a  peculiar,  well-known,  aromatic 
one;  it  is  altered  by  certain  foods,  for  instance,  the  violet  stench 
after  eating  asparagus,  and  the  garlicky  odor  after  using  garlic. 

The  average  composition  of  normal  urine  is  given  as  follows: 


(Parts  in 
1000.) 

Water 950.00 

Urea 28  .  00 

Uric  acid 0.60 

Hippuric  acid o-SSf' 

Creatinin 0.65 

Extractives 8.00 


Voided  per  Day. 


Organic 
matter, 
37.60. 


Grains 

520 . 80 

II .  16 

6.51 
12  .  09 

148.80 


Grams* 

0.75 

0.44 

0.81 

10 .  00 


Sodium  chlorid 

Phosphoric  acid 

Sulphuric  acid 

Lime  (CaO) 

Magnesia  (MgO) 

Potash    (KgO)    and  soda 
(Na^O) 


8.00 
2  .  00 


25 
30 


o .  60 


Inorganic 

matter, 

12  .40 


148.80 
37.20 

34.45 
4.65 

5.58 
II .  16 


10 .  00 
2.50 

1.56 
0.31 

0-37 
0.75 


Total 1000  .  00 


930.20  62.49 


336  THE    URINE. 

Urea  may  be  increased  in  febrile  affections,  diabetes,  in 
chronic  interstitial  nephritis,  and  acute  inflammatory  con- 
ditions, and  after  the  ingestion  of  excessive  quantities  of  al- 
buminous food  and  certain  drugs.  It  may  be  determined 
qualitatively  by  the  addition  of  nitric  acid  to  urine  which 
has  been  evaporated  to  about  one-sixth  its  original  volume. 
Crystals  of  urea  nitrate  will  then  be  formed.  For  the  quan- 
titative determination  of  urea  in  the  urine,  two  tests  are  em- 
ployed—Davy's and  Fowler's  tests. 

Davys  Hypobromite  of  Sodium  Test. — Fill  a  graduated 
glass  tube  one-third  full  of  mercury,  and  add  1/2  dram  of  the 
twenty-four  hours'  urine;  then  fill  the  tube  evenly  full  with 
a  saturated  solution  of  hypobromite  of  sodium,  and  close  it 
immediately  with  the  thumb;  invert  the  tube  and  place  its 
open  end  beneath  a  saturated  solution  of  chlorid  of  sodium; 
the  mercury  flows  out  and  is  replaced  by  the  solution  of  salt; 
nitrogen  gas  is  disengaged  from  the  urea  in  the  upper  part  of 
the  tube.  Each  cubic  inch  of  gas  represents  0.645  g^-  ^^  urea 
in  the  half-dram,  from  which  the  amount  passed  in  twenty- 
four    hours    may    be  calculated. 

Fowler  s  Sodium  Hypochlorite  Test. — This  test  depends  upon 
the  reduction  in  density,  caused  by  the  decomposition  of 
urea  in  solution  by  sodium  hypochlorite.  In  a  mixture  of 
one  volume  of  urine  and  seven  volumes  of  sodium  hypo- 
chlorite solution,  a  loss  of  one  degree  in  specific  gravity  re- 
presents the  decomposition  of  o.  7  7  per  cent,  of  urea.  The  specific 
gravity  of  the  urine  should  always  be  taken  first.  The  spe- 
cific gravity  of  the  mixture  of  the  urine  and  the  hypochlorite 
solution  (Labarraque's  solution)  should  then  be  ascertained 
by  multiplying  that  of  the  pure  sodium  hypochlorite  solution 
by  seven,  adding  to  this  the  specific  gravity  of  the  urine,  and 
dividing  by  eight.  The  mixture  (i  part  urine  and  7  parts 
hypochlorite  solution)  is  set  aside  for  about  two  hours  to 
allow  complete  decomposition,  when  the  specific  gravity  is 
again  taken   and   compared  with   that   of   the  urine. 

A  diminution  in  the  quantity  of  urea  usually  indicates  de- 
ficient elimination,   and  is  observed  in  nephritis,  especially  in 


THE    URINE. 


337 


the  late  stages,  cachectic  conditions,  acute  yellow  atrophy 
of  the  liver,  hepatic  cirrhosis,  diarrhea,  acute  gout,  chronic 
rheumatism,  leprosy,  pemphigus,  melancholia,  catalepsy, 
hysteria,  and  after  free  perspiration,  fasting,  and  a  vegetable 
or  milk  diet. 

Uric  acid  or  urates  in  the  urine  constitute  the  condition 
known  as  lithuria.  When  in  excess  in  the  urine  they  are  pre- 
cipitated by  cold  as  brickdust  deposits.  Their  quantity  is 
increased  in  indigestion,  gout,  fever,  wasting  diseases,  ma- 
laria, scurvy,  diabetes,  rachitis,  and  after  free  perspiration 
and  diarrhea,  and  the  ingestion  of  nitrogenous  foods,  colchi- 
cum,  salicylic  acid,  and  corrosive  sublimate.  They  are 
diminished  in  amount  in  an  acute  attack  of  gout,  anemia, 
chlorosis,  chronic  nephritis,  'and  after  the  use  of  drugs,  such 
as  caffein  lithia,  potassium  iodid,  etc. 


Fig.  27. — Uric  acid  crystals.     (Greene's         Fig.      28. — Ammonio-magnesium     (triple) 
Medical  Diagnosis.)  phosphate.   (Greene's  Medical  Diagnosis.) 


Tests  for  Uric  Acid  and  Urates. — The  urine  should  be  evap- 
orated to  dryness  on  a  water-bath  and  covered  with  strong 
nitric  acid,  after  which  the  mixture  is  again  evaporated.  When 
cool  a  drop  or  two  of  ammonium  hydroxid  is  added  to  the 
residue,  whereupon  a  beautiful  red  color  will  be  produced  by 
the  formation  of  murexid  or  ammonium  purpurate. 

The  contact  test  consists  in  pouring  nitric  acid  slowly  down 
the  side  of  a  test-tube  containing  a  small  quantity  of  urine. 
At  the  junction  of  the  two  liquids  a  yellowish    red   zone  will 


338 


THE    URINE. 


be  formed  by  the  uric  acid,  while  above  this  will  be  a  dense 
milky  zone  of  acid  urates,   which  dissolves  on  agitation. 

For  the  quantitative  determination  of  uric  acid,  three 
ounces  of  the  twenty-four  hours'  urine  (after  being  slightly 
acidulated,  boiled,  and  filtered  while  hot)  should  be  mixed 
with  one-tenth  as  much  nitric  acid  and  placed  in  a  cool  place 
for  twenty-four  hours.  The  uric  acid  crystals  are  then 
collected  on  a  weighed  filter,  washed,  and  dried  at  212°  F. 
The  increased  weight  represents  the  quantity  of  uric  acid  in 
3  ounces  of  urine. 


Fig.     29. — Ammonium     urate. 
{Greene's  Medical  Diagnosis.) 


Fig.  30. — Calcium  oxalate  crystals. 
{Greene's  Medical  Diagnosis.) 


Phosphates  occur  in  the  urine  as  ammonio-magnesium  or 
triple  phosphates,  and  as  crystalline  and  amorphous  phos- 
phate of  calcium.  They  are  precipitated  in  alkaline  urine 
and  often  produce  a  cloudiness  when  the  urine  is  heated, 
which  disappears  on  the  addition  of  nitric  or  acetic  acid.  The 
addition  of  an  alkali  such  as  ammonium  hydroxid  to  urine 
containing  amorphous  phosphates  causes  their  precipitation. 
Triple  phosphates  may  be  recognized  under  the  microscope 
by  their  large  rhombic  or  "coffin-lid"  shaped  prisms,  which 
are  freely  soluble  in  acetic  acid.  Crystalline  phosphate  of 
calcium  is  a  rare  form  and  appears  as  rods  or  needles,  some- 
times grouped  together  as  sheaves  or  stars,  which  are  also 
soluble  in  acetic  acid.  An  excess  of  phosphates  in  the  urine 
constitutes  phosphaturia,  and  occurs  in  rachitis,    osteomalacia. 


THE    URINE.  339 

gout,  nervous  dyspepsia,  and  various  nervous  affections. 
They  are  apparently  in  excess  in  alkaline  urine.  Triple  phos- 
phate in  combination  with  amorphous  phosphates,  bladder 
epithelium,  and  pus  cells  in  freshly  voided  urine  indicates 
cystitis. 

The  magnesium  test  for  phosphates  consists  in  the  addition 
of  a  mixture  of  i  part  each  of  magnesium  sulphate,  ammo- 
nium chlorid,  and  ammonium  hydroxid  and  8  parts  of  distilled 
water  to  three  times  as  much  urine,  whereupon  a  cloudy, 
milky  precipitate  will  be  formed  which  will  be  creamy  if  the 
phosphates  are  in  excess. 

Chlorids  are  increased  in  the  urine  after  exertion  of  any 
kind,  in  acute  Bright's  disease,  diabetes  insipidus,  and  dur- 
ing absorption  of  exudates;  and  are  diminished  in  pneumonia, 
febrile  affections,  and  chronic  nephritis,  and  wasting  diseases. 
To  test  for  their  presence,  albumin  should  first  be  removed 
by  nitric  acid,  or  boiling  and  filtration,  after  which  i  drop 
of  silver  nitrate  solution  (i  .part  to  8)  should  be  added.  The 
presence  of  chlorids  will  be  indicated  by  a  white  precipitate 
of  silver  chlorid. 

Oxalates  are  recognized  only  by  microscopic  examination, 
and  occur  as  dumb-bell  shaped  crystals  or  octahedral  crystals. 
Their  presence  is  termed  oxaluria,  and  indicates  impeded  meta- 
morphosis. It  is  encountered  in  diabetes,  after  the  ingestion  of 
pears,  rhubarb,  spinach,  and  similar  substances,  in  certain 
forms  of  indigestion,  in  gout,  and  in  certain  nervous  affections. 
It  is  accompanied  by  pains  in  the  back  and  loins,  flatulence, 
dyspepsia,  hypochondriasis,  and  melancholia. 

Cystin  is  a  rare  sediment  sometimes  observed  in  the  urine 
of  children  and  young  male  adults,  and  in  occasional  instances 
it  forms  a  basis  for  a  calculus.  It  occurs  as  hexagonal  plates 
v/hich  may  be  superimposed  upon  each  other  or  grouped  in 
irregular  masses. 

Leucin  appears  in  the  urine  as  highly  refracting  spheres, 
which  have  a  radiating  arrangement  and  are  insoluble  in 
ether.  They  are  usually  combined  with  tyrosin  crystals, 
which  are  long  and  needle-like,  in  acute  yellow  atrophy  of  the 


340 


THE    URINE. 


liver  and  phosphorus  poisoning.  Tyrosin  may  also  be  found 
in  typhoid  fever. 

Cholesterin  plates  may  be  encountered  in  the  urine  in  jaun- 
dice, chyluria,  fatty  degeneration  of  the  kidneys,  and  dia- 
betes. 

Mucus  alone  is  not  visible,  but  induces  cloudiness  from  hav- 
ing entangled  and  precipitated  mucous  or  pus  corpuscles, 
epithelium,    and   various    crystals.     To    detect    its    presence    a 


Fig.  31. — A,  crystals  of  cystin.     B,  crystals  of  oxalate  of  lime.     C,  hour-glass  forms  of 

B.  {Landois .) 


few  drops  of  acetic  acid  are  added  to  the  urine,  thereby  rend- 
ering visible  threads  and  bands  of  mucin  which  are  dissolved 
on  the  addition  of  nitric  acid. 

Albumin  occurs  in  the  urine  usually  in  the  form  of  serum 
albumin,  but  other  proteids  may  also  be  found.  It  is  encount- 
ered in  congestion  and  inflammation  of  the  kidneys,  anemic 
conditions,  pregnancy,  acute  febrile  diseases,  diarrhea,  cholera, 
certain  nervous  diseases  as  meningitis,  cerebral  hemorrhages, 
epilepsy,  etc.,  and  in  healthy  adults  after  exertion,  exposure, 
or   a   rich    diet.      Contamination   of   the   urine   with   blood    or 


THE    URINE. 


341 


pus,    anywhere    along    the    genitourinary    tract    produces    the 
form    known    as    extrarenal    albuminuria. 

Heller  s  Test. — A  small  quantity  of  nitric  acid  should  be 
placed  in  the  test-tube  and  an  equal  quantity  of  urine  super- 
imposed upon  it  by  means  of  a  pipette.  ~A  white  zone  at  the 
line  of  junction  will  result  if  albumin  is-  present.  A  diffuse 
pink  ring,  slightly  above  the  line  of  contact,  indicates  the 
presence  of  uric  acid.  Balsam  of  copaiba,  oleoresin  of  cubebs, 
turpentine,  and  similar  drugs,  when 
ingested,  give  rise  to  the  same  reac- 
tion in  the  urine  as  albumin,  but 
their  rings  are  dissolved  by  the  addi- 
tion of  alcohol. 

Heat  and  Nitric  Acid  Test. — The 
urine  is  slightly  acidulated  and 
boiled.  A  white  deposit,  which  is 
not  dissolved  by  the  addition  of 
nitric  acid,  drop  by  drop,  is  due  to 
coagulated  albumin.  An  excess  of 
the  acid  will  cause  solution  of  the 
precipitate. 

Johnsons  Picric  Acid  Test.  —  Filtered  urine  should  be 
placed  in  a  test-tube  and  a  saturated  solution  of  picric  acid 
is  added,  drop  by  drop;  in  the  presence  of  albumin  an  opaque 
white  cloud  will  be  formed,  which  is  rendered  more  marked 
on  the  application  of  heat. 

Quantitative  Test. — For  the  determination  of  the  quantity 
of  albumin  Esbach's  albuminometer  is  most  convenient.  The 
tube  should  first  be  filled  up  to  the  mark  "U"  with  urine. 
The  reagent,  consisting  of  picric  acid  10  gm.,  citric  acid  20 
gm.,  and  water  i  liter,  should  be  poured  over  the  urine  until 
the  mark  "R"  is  reached.  The  rubber  stopper  is  then  in- 
serted and  the  contents  of  the  tube  thoroughly  admixed  by 
gentle  shaking.  The  tube  is  then  set  aside  for  twenty-four 
hours,  when  a  precipitate  will  have  formed  and  its  quantity 
vvill  indicate  on  the  graduated  scale  on  the  tube  the  number 
of  grams  of  albumin  to  the  liter  of  urine. 


Fig.      32. — Tyrosin.      {Greene's 
Medical  Diagnosis.) 


342 


THE   URINE. 


Sugar  in  the  urine  or  glycosuria  may  be  present  normally, 
after  the  ingestion  of  large  quantities  of  saccharine  substances, 
but  is  usually  present  as  an  abnormal  constituent  in  diabetes 
mellitus,  and  diseases  of  the  pancreas.  It  may  also  occur 
in  diseases  or  injuries  of  the  floor  of  the  fourth  ventricle, 
certain  nervous  diseases,  pregnancy,  and  poisoning  by  drugs, 
such  as  chloroform,  nitrites,  etc. 

Moore's  test  for  sugar  consists  in  boiling  the  urine  with  half 
its  volume  of  sodium  or  potassium  hydroxid  solution  (lo  per 
cent.).  Should  a  white  flaky  precipitate  of  earthy  phos- 
phates be  formed,  it  should  be  removed  by  filtration  and  the 
urine  again  boiled.  If  glucose  is  present,  the  liquid  then  be- 
comes brown  and  finally  black,  due  to  the  formation  of  glucic 
and  finally  melassic  acid. 

Boettgers  bismuth  test  requires,  first,  the  addition  of  the 
urine  to  half  its  volume  of  sodium  or  potassium  hydroxid 
solution,  after  which  a  small  portion  of  bismuth  subnitrate 
is  mixed  with  the  resultant  liquid  and  the 
whole  shaken  together  and  boiled.  The 
presence  of  sugar  reduces  the  salt,  and  black 
metallic  bismuth  is  deposited.  If  there  is 
but  little  glucose,  a  gray  precipitate  is  formed. 
If  there  is  any  reason  to  suspect  the  pres- 
ence of  albumin,  it  should  be  removed  be- 
fore applying  this  test,  as  it  interferes  by 
forming  bismuth  sulphid,  which  is  also 
black. 

Johnson's  picric  acid  test  is  applied  by 
adding  a  few  drops  of  a  saturated  solution 
of  picric  acid  to  urine,  which  has  been  previously  rendered 
alkaline  by  means  of  a  sodium  or  potassium  hydroxid  solution 
and  boiling  the  mixture,  which  then  becomes  claret-red  in  color 
in  the  presence  of  glucose.     Creatinin  gives  a  similar  reaction. 

Trommer' s  test  is  performed  by  adding  to  the  urine  a  few 
drops  of  a  solution  of  cupric  sulphate,  and  then  its  own  volume 
of  a  potassium  hydroxid  solution,  after  which  the  entire  mix- 
ture is  boiled.      The  immediate  formation  of  a  yellowish  pre- 


FlG 


3  3 . — Cholesterin. 
{Landois.) 


THE    URINE.  343 

cipitate  of  hydrated  cupric  suboxid  denotes  the  i:»resence  of 
sugar. 

The  phenyl-hydrazin  test  requires  for  its  reagent  a  mixture 
of  2  gr.  of  phenyl-hydrazin  hydrochlorid  and  3  gr.  of  sodium 
acetate  dissolved  in  half  a  test-tube  full  of  water,  by  heating. 
The  test-tube  is  then  filled  with  the  suspected  urine  and  placed 
in  boiling  water  for  fifteen  or  twenty  minutes.  It  is  then 
placed  in  cold  water.  If  the  sugar  is  present  in  large  amounts 
a  yellow  precipitate  of  needle-like  crystals  may  be  observed 
with  the  unaided  eye,  but  ordinarily  the  microscope  is  neces- 
sary   to    detect    these    crystals    of    phenyl-glucosazon. 

Quantitative  Tests  for  Glucose. — Fehlings  test  necessitates 
fresh  preparation  of  the  reagent  before  its  application.  Two 
solutions  are  employed:  the  first  consists  of  34.652  gm.  of 
pure  cupric  sulphate  dissolved  in  distilled  water  and  diluted 
up  to  5C0  c.c,  the  second  consists  of  175  gm.  of  pure  Rochelle 
salt  and  60  gm.  of  caustic  soda,  dissolved  in  400  c.c.  of  dis- 
tilled water  and  boiled,  after  which  it  is  made  up  to  500  c.c. 
with  distilled  water.  The  Fehling's  solution  proper  is  made 
by  mixing  equal  quantities  of  the  foregoing  solutions,  and 
its  preparation  is  such  that  i  c.c.  of  it  will  reduce  0.005  gm.  of 
glucose.  In  applying  this  test,  i  c.c.  of  Fehling's  solution  is 
boiled  with  4  c.c.  of  distilled  water  to  test  it.  If  the  solution 
remains  clear  the  urine  is  added,  drop  by  drop,  by  means  of 
a  graduated  pipette,  from  which  2  drops  equal  i/io  c.c. 
The  number  of  drops  necessary  to  change  all  of  the  blue  color 
of  the  solution  to  yellowish  red,  on  boiling,  should  be  noted 
and  divided  by  two,  thus  giving  the  number  of  i/io  c.c.  re- 
quired. If  I  c.c.  has  been  required  for  this  purpose,  it  indicates 
the  presence  of  0.5  per  cent,  of  sugar,  and  if  2  c.c.  have  been 
employed  the  percentage  will  be  0.25.  This  result  is  obtained 
by  dividing  the  number  5  by  the  number  of  tenths  of  urine 
required  to  reduce  the  Fehling's  solution. 

Robert's  differential  density  test  consists  in  taking  two 
measured  specimens  of  the  urine,  to  one  of  which  is  added  a 
small  piece  of  yeast.  Both  are  placed  in  a  chamber  at  a  tem- 
perature from  75°  to  80°  F.  for  twenty-four  hours,  after  which 


344  THE   URINE. 

the  specific  gravity  of  each  is  taken.  The  presence  of  sugar 
will  cause  a  loss  of  specific  gravity,  and  the  number  of  de- 
grees lost  will  correspond  approximately  to  the  number  of 
grains  of  sugar  in  each  ounce  of  urine. 

Blood. —  Blood  occurs  in  the  urine  in  two  forms:  (i)  hema- 
turia, in  which  hlood  corpuscles  are  in  the  urine;  and  (2)  hem- 
oglobinuria,  in  which   hlood  pigment  is   in  the  urine. 

In  kem,aturia  a  microscopical  examination  will  show  nu- 
merous red  blood  corpuscles  in  the  urine ;  in  the  other  condition 
red  cells  are  either  absent  or  are  very  scanty. 

The  principal  causes  of  hematuria  are:  (i)  conditions  in  which 
the  blood  is  affected,  as  in  the  infectious  diseases,  in  scurvy, 
pernicious  anemia,  and  purpura;  (2)  traumatism  or  inflamma- 
tions in  any  part  of  the  urinary  tract;  (3)  congestion  of  the 
kidneys  secondary  to  disease  of  the  lungs,  heart,  or  liver. 

The  principal  causes  of  hemoglobinuria  are:  poisons,  such 
as  arsenic,  potassium  chlorate,  carbolic  acid,  carbon  monoxid; 
jaundice,  malaria,  syphilis,  Raynaud's  disease,  scurvy,  pur- 
pura; condition  of  hemolysis,  such  as  Blackwater  fever. 

Source  of  the  Hemorrhage. — This  can  readily  be  ascertained  as 
follows:  if  the  blood  is  chiefly  in  the  first  urine  passed,  it 
comes  from  the  urethra;  if  in  the  last  only  or  chiefly,  it  is  from 
the  bladder;  and  if  the  blood  and  urine  are  well  mixed  it  is 
from  the  kidneys. 

Tests  for  Blood. — Heat  and  nitric  acid  causes  a  deposition 
of  the  albumin  of  the  blood,  with  changing  of  its  coloring 
matter  to  a  dirty  brown. 

Heller's  test  consists  in  boiling  the  urine,  then  adding  caustic 
soda  and  continuing  to  boil,  thus  causing  a  precipitation  of 
the  phosphates  and  coloring  matter  of  the  blood,  which  de- 
posit appears  of  a  brownish-red  color  and  the  supernatant 
fluid  of  a  bottle-green  color. 

The  microscope  and  spectroscope  should  also  be  employed 
as  confirmatory  tests. 

Bile. — The  presence  of  biliary  pigments  may  be  crudely 
determined  by  agitating  the  urine,  whereupon  a  yellow  foam 
is    produced.     A    simple    test    is    to    filter    the    urine    through 


THE    URINE.  345 

white  filter  paper;  then  place  the  paper  on  a  porcelain  dish  or 
plate  and  add  a  drop  of  strong  nitric  acid.  In  the  presence 
of  bile  pigment,  concentric  rings  of  red,  violet,  blue,  and 
green  will  be  formed  at  the  line  of  contact. 

Gmelins  test  is  performed  as  follows:  put  3  c.c.  of  nitric 
acid  in  a  test-tube,  add  a  small  piece  of  wood  (a  piece  of  a 
match  will  do),  and  heat  until  the  acid  is  yellow;  let  it  cool. 
When  cold,  float  on  the  surface  of  the  acid  some  of  the  urine 
to  be  tested.  In  the  presence  of  bile,  there  will  be  a  green 
band  at  the  junction  of  the  two  liquids,  and  this  will  grad- 
ually  rise,    and   be    succeeded   by   blue,    violet,    and  yellow. 

Pettenkofer's  test  consists  first  in  the  addition  of  a  few  grains 
of  cane-sugar  and  a  drop  or  two  of  sulphuric  acid  to  the  urine, 
after  which  the  entire  mixture  is  boiled.  The  formation,  if 
a  violet-red  color,    indicates  the   presence   of  biliary  pigments. 

Pus. — The  presence  of  pus  in  the  urine  is  termed  pyuria 
and  usually  indicates  suppuration  along  the  genitourinary 
tract.  Its  source  may  be  detected  to  a  great  extent  by  the 
time  of  its  appearance  in  flow,  as  with  blood  in  the  urine. 
When  present  in  the  early  part  of  micturition  the  urethra  is 
usually  diseased,  if  at  the  end  and  in  alkaline  urine  the  trouble 
is  in  the  bladder,  but  if  it  is  freely  admixed  with  an  acid 
or  neutral  urine,  the  probabilities  are  that  the  kidneys  are  at 
fault.  The  addition  of  an  equal  quantity  of  a  solution  of 
potassium  hydroxid  to  urine  containing  pus  gives  rise  to  the 
formation  of  a  viscid  gelatinous  mass.  The  microscope  may 
also  be  employed  to  detect  pus. 

Acetone. — Acetone  occurs  in  the  urine  in  the  advanced 
stages  of  diabetes,  in  starvation,  in  cancer,  in  autointoxi- 
cations, in  digestive  disturbances,  in  fevers,  in  certain  psy- 
choses,   and   to    a   very    slight    extent    in   health. 

LegaVs  test  for  its  detection  consists  in  the  addition  of  a 
few  drops  of  a  strong  solution  of  sodium  nitroprussid  to  about 
4  c.c.  of  urine  which  has  been  previously  rendered  alkaline 
by  potassium  hydroxid  solution.  In  the  presence  of  acetone 
a  red  color  is  produced,  which  turns  purple  on  the  addition  of 
a  few  drops  of  acetic  acid. 


346  THE   URINE. 

It  may  also  be  detected  by  the  precipitation  of  iodoform, 
which,  occurs  when  urine  containing  it  is  mixed  with  a  few 
drops  of  iodopotassium  iodid  solution  and  sodium  hydroxid 
solution. 

Diacetic  Acid. — Diacetic  acid  occurs  in  children  in  fevers, 
in  diabetes,  and  in  autointoxications.  Coma  usually  follows 
its  appearance.  To  detect  its  presence  the  urine  should  be 
boiled  with  a  solution  of  ferric  chlorid,  and  if  diacetic  acid  is 
present,  a  Burgundy-red  color  will  be  produced. 

Indican. — The  presence  of  indoxyl-potassium  sulphate  or 
indican  in  the  urine  is  termed  indicanuria.  It  is  a  sign  of 
intestinal  putrefaction  and  is  observed  after  the  ingestion 
of  an  animal  diet,  in  ileus,  peritonitis,  diarrhea,  and  intestinal 
tuberculosis.  It  also  accompanies  decomposition  of  albumin 
in  cavities,  and  is  encountered  in  empyema  and  puerperal  peri- 
tonitis.     It  is  not  present  in  simple  constipation. 

Jaffes  test  consists  in  mixing  lo  c.c.  of  strong  hydro- 
chloric acid  with  an  equal  volume  of  urine,  from  which  albu- 
min has  been  removed,  and  while  shaking  add,  drop  by  drop,  a 
freshly  prepared  saturated  solution  of  chlorid  of  lime.  Chloro- 
form is  then  added,  which  dissolves  out  an  indigo-blue  sub- 
stance if  indican  is  present. 

Another  method  sometimes  employed  requires  the  addi- 
tion of  20  drops  of  urine  to  4  c.c.  of  hydrochloric  acid.  If  the 
proportion  of  indigo  be  slightly  above  normal,  the  resultant  color 
will  be  rather  light  yellow ;  if  in  excess  the  acid  will  turn  violet 
or  blue — the  color  being  more  intense  the  greater  the  quan- 
tity. If  no  coloration  appears  within  a  minute  or  two  there 
is  no  excess  of  indican. 

Peptone. — Peptone  may  be  encountered  in  the  urine  in 
jaundice,  hepatic  cancer,  acute  miliary  tuberculosis,  scarlet 
fever,  and  typhoid  fever. 

Ralfe's  test  is  performed  by  adding  4  c.c.  of  Fehling's  solu- 
tion to  a  small  quantity  of  urine  by  means  of  a  pipette.  Pep- 
tone will  be  indicated  by  a  rose-colored  halo  immediately 
above  the  line  of  contact. 

Ehrlich*s    Diazo -reaction. — The    presence   of    aromatic    sub- 


THE    URINE. 


347 


stances  in  the  urine,  such  as  occur  in  typhoid  fever,  pneu- 
monia, measles,  tuberculosis,  and  septic  infection,  may  be  de- 
tected by  the  following  test: 

I.  Take  2  gm.   (30  gr.)  of  sulphanilic  acid,  50  c.c.  of  hydro- 
chloric   acid,  and  1000  c.c.  of  distilled  water. 

II.  Take  solution  sodium  nitrite  in  water  of  the  strength  of 


Fig.  34. — Illustrating  the  Forma. 
TiON  OF  Casts.  {Rindfleisch.) 
a.  Hyaline  casts  in  place.  If  it 
comes  away  bringing  nothing  with  it, 
it  will  remain  a  hyaline  cast.  If  it 
brings  epithelium,  it  will  be  an 
epithelial  cast;  if  the  epithelium  is 
granular,  it  will  be  a  granular  cast;  if 
fatty,  a  fatty  cast.  c.  Granular  cast. 
The  two  casts  in  the  lower  comer  and 
to  the  left  are  hyaline ;  the  remaining 
casts  are  largely  hyaline,  but  bear  a 
few  epithelial  cells. 


Fig.  35. — Blood - 
cells  and  blood  - 
cast.      (Landois.) 


0.5  per  cent.  Place  50  parts 
of  No.  I  and  i  part  No.  II  in 
a  test-tube  and  add  equal 
amounts  of  urine.  The  entire 
mixture  is  rendered  strongly 
alkaline  by  strong  ammonia 
water. 

If  the  diazo-reaction  occurs 
the  mixture  becomes  carmine 
red;  now  shake  the  tube,  and 
if  the  red  color  is  seen  in  the 
Allow  the  tube  to  stand  a  day,  and 


foam  the  test  is  complete 
a  green  precipitate  forms. 

Microscopic  Examination. — For  the  determination  of  sub- 
stances by  the  microscope,  other  than  the  crystals  already 
mentioned,  it  is  necessary  to  produce  first,  a  sediment  by 
means  of  the  centrifuge,  or  in  its  absence,  by  allowing  the 
urine  to  stand  for  twelve  or  twenty-four  hours  after  having 


348 


THE   URINE. 


added  lo  drops  of  chloroform,  5  gr.  of  chloral,  formalin,  or  a 
few    drops    of    carbolic    acid    to    prevent    decomposition. 

In  all  microscopical  examinations  of  urinary  sediment, 
do  not  allow  more  light  on  the  stage  than  is  absolutely  neces- 
sary,   the   dimmer   the   better;    and   focus    carefully. 

Tube-casts  should  always  be  carefully  sought  for  in  the  sed- 
iment.    They  are    molds    of    the    uriniferous  tubules  and  vary 


B 


Fig.  36. — Epithelial  Casts.  (Landois.) 
A,  Epithelial  cast,  the  lower  end  of  which 
is  coarsely  graniilar;  B,  epithelial  cast  in 
which  the  epithelial  cells,  though  themselves 
granular,  have  not  broken  up. 


Fig.  37. — Granular  Casts.  (Landois.) 
A,  Granular  casts  in  which  the  gran- 
ules are  fine  and  the  dissolution  of  the 
epithelial  cells  is  complete;  B,  granular 
casts  in  which  the  granules  are  coarse 
and  the  outlines  of  the  epithelial  cells 
at  points  faintly  distinguishable. 


in  character  according  to  the  existing  abnormal  condition  of 
the  kidneys.  Usually  they  are  composed  of  albuminoid  sub- 
stances, but  there  may  be  in  addition  epithelium,  degenerated 
cells,  blood  corpuscles,  or  fat  globules.  Their  length  is  about 
200  microns  or  more,  and  their  width  from  4  to  40  microns. 
While  usually  straight,  they  may  be  cuived  or  twisted  upon 
themselves. 

Blood-casts    are    composed    of    coagulated    blood    and    blood 
cells,  and  point  to  the  presence    of    some    hemorrhagic   condi- 


THE    URINE. 


349 


tion  of  the  kidney.  (Jften  the  cast  is  in  reahty  a  hyaline  cast 
studded  with  blood  corpuscles. 

Epithelial  casts  may  also  be  considered  as  hyaline  casts 
covered  and  infiltrated  with  epithelial  cells.  They  denote 
desquamation,  and  are  seen  in  the  urine  and  in  acute  paren- 
chymatous nephritis. 

Fatty  casts  are  those  in  which  the  coagulated  material  form- 
ing  the    molds    of   the   tubules    is   studded   with   oil    globules' 


^, 


Fig.  38. — a,  Hyaline  cast;  6,  hyaline  cast 
with  a  few  attached  leukocytes;  c,  hyaline 
cast  with  attached  epithelium,  truly  an 
epithelial  cast.      (Landois.) 


Fig.  39. — Tubercle  bacilli  in 
urine.  Observe  tendency  to 
form  groups.  (Greene's  Medi- 
cal Diagnosis.) 


They  indicate  fatty  degeneration  of  the  kidney  and  occur  in 
chronic  parenchymatous  nephritis. 

Granular  casts  are  made  up  of  coagulated  material  and 
granular  debris.  They  are  usually  observed  in  contracted 
kidney. 

Hyaline  casts  or  mucous  casts,  are  transparent,  delicate 
cylinders.  They  may  occur  in  health,  but  are  always  ob- 
served   in  congestion  or  inflammation  of  the  kidney. 

Pus  casts  are  made  up  of  albuminous  material,  degener- 
ated leukocytes,  and  bacteria,  and  are  indicative  of  renal  sup- 
puration. 

Waxy  casts   are  large   and   yellowish   in   color,   and   give   the 


350  CONGESTION    OF    THE    KIDNEYS. 

amyloid  reaction.  They  are  present  in  chronic  parenchy- 
matous   nephritis. 

Cylindroids  resemble  hyaline  casts,  but  are  longer,  more 
tapering,   and  constricted.     They  have  no  clinical  significance. 

To  examine  the  urine  for  tubercle  bacilli,  the  sediment 
must  be  thoroughly  centrifuged,  and  then  examined  in  the 
same  way  that  sputum  is  (see  page  504);  but  a  small  amount 
of  egg  albumin  is  added  to  the  specimen  before  it  is  placed  on 
the  slide  or  coverslip. 

Spermatoza  are  recognized  by  their  characteristic  form 
and  motility. 


DISEASES  OF  THE   KIDNEYS  AND  BLADDER. 

CONGESTION  OF  THE  KIDNEYS. 

Synonyms. — Renal    hyperemia;    catarrhal    nephritis. 

Definition. — An  increase  in  the  amount  of  blood  in  the 
vessels  of  the  kidneys ;.  when  arterial,  it  is  termed  active  con- 
gestion; when  venous,  passive  congestion;  characterized  by 
pain,  frequent  desire  for  urination,  and  scanty,  high-colored 
urine,  occasionally  containing  albumin  or  blood. 

■  Causes. — Active;  cold;  irritating  substances  eliminated  by 
the  kidneys,  as  turpentine,  copaiba,  cantharides,  carbolic  acid, 
nitrate  or  chlorate  of  potassium;  the  eruptive  or  continued 
fevers;   injuries  over  the  kidneys;  pregnancy. 

Passive:  obstructive  diseases  of  the  heart  or  lungs,  pres- 
sure of  the  pregnant  uterus. 

Pathologic  Anatomy. — The  kidneys  enlarge  and  increase  in 
weight;  redness  increases  (the  color  being  bluish  if  passive), 
with  points  of  vascularity,  corresponding  to  the  Malpighian 
bodies,  and  occasionally  minute  ecchymoses.  The  abnormal 
hyperemia  causes  a  catarrhal  state  of  the  ducts  of  the  pyr- 
amids, with  shedding  of  their  epithelium. 

If  mechanical  {passive)  obstruction  continues  for  some 
time,    increase    of   the    connective  tissue    with    consequent    in- 


CONGESTION    OF    THE    KIDNEYS.  351 

duration  and  contraction  results,  a  form  of  chronic  Bright's 
disease. 

Symptoms. — Active  variety:  pain  over  kidneys  and  follow- 
ing the  course  of  the  ureters  into  the  testicles  and  penis,  irri- 
table bladder,  almost  constant  and  pressing  desire  for  urin- 
ation, the  urine  scanty,  high-colored,  and  occasionally  bloody, 
with  fibrin,  casts,  and  albumin;  there  is,  as  a  rule,  no  pain  dur- 
ing the  act  of  urination.  The  constitutional  symptoms  are 
headache,  slight  nausea,  vomiting,  and  a  general  feeling  of 
discomfort.  If  the  condition  persists,  inflammation  of  the 
kidney  results. 

Passive:  the  kidney  changes  are  masked  by  the  lung  or 
heart  trouble,  until  dropsy,  and  scanty  high-colored  albuminous 
urine  are  observed. 

Prognosis. — Active:  if  recognized  and  properly  treated, 
favorable. 

Passive:  controlled  by  the  cause,  and  if  prolonged  termin- 
ating in  interstitial  nephritis. 

Treatment. — The  most  important  indication  is  to  ascertain 
and  remove  the  cause.  Rest  in  bed  is  necessary.  Liquid 
diet  and  saline  purgatives  should  be  adminstered.  A  warm 
bath,  diaphoretics,  and  dry  or  wet  cups  over  the  loins  should 
be  employed.  Infusion  of  digitalis  and  bland  drinks  are  in- 
dicated. Irritability  of  the  bladder  may  be  relieved  by  cam- 
phor, gr.  ii  to  iv  (0.13  to  0.26  gm.),  every  four  hours,  alone  or 
combined  with  morphin  sulphate,  gr.  1/12  to  1/6  (0.005  to 
o.oii     gra.),    or    by    morphin    hypodermically. 

The  treatment  of  the  passive  form  resolves  itself  into  the 
treatment  of  the  cause,  remembering  that  there  is  too  much 
blood  in  the  veins  and  too  little  in  the  arteries.  There  are 
three  ways  of  restoring  the  circulation :  by  venesecting,  opening 
a  large  vein;  by  increasing  the  power  of  the  heart  by  the  use 
of  digitalis  or  strophanthus,  preferably  the  first  named;  and  by 
dilatation  of  the  capillaries  with  inhalations  of  amyl  nitrite 
or  the  internal  use  of  nitroglycerin  (i  per  cent,  solution), 
nxj  to  iij  (0.06  to  0.18  c.c.)  every  four  hours.  The  bowels 
should    be    kept    open    by    salines. 


352  ACUTE    PARENCHYMATOUS    NEPHRITIS. 

ACUTE  PARENCHYMATOUS  NEPHRITIS. 

Synonyms. — Acute  Bright's  disease;  acute  desquamative 
nephritis;    acute    tubal    nephritis;    acute    croupous    nephritis. 

Definition. — An  acute  inflammation  of  the  epithelium  of 
the  uriniferous  tubules,  characterized  by  fever,  scanty,  high- 
colored,  or  smoky  urine,  dropsy,  with  more  or  less  constant 
nervous  phenomena,  the  result  of  acute  uremia. 

Causes. — Cold  and  exposure,  scarlatina,  diphtheria,  ma- 
laria, and  other  infectious  diseases,  traumatism  to  the  back, 
pregnancy,  and  the  persistent  use  of  irritants,  such  as  tur- 
pentine, cantharides,  phosphorus,  ginger,  etc.,  are  the  most 
common  causes.  It  may  also  be  associated  with  certain  skin 
diseases,  extensive  burns  of  the  skin,  and  simple  follicular 
tonsillitis.      The   affection   is   most   frequent   in   childhood. 

Pathologic  Anatomy. — The  kidneys  are  generally  swollen, 
engorged,  more  vascular,  and  of  red  color;  in  the  second  stage 
the  organ  remains  large,  irregularly  red,  especially  the  cortex; 
the  tubules  are  engorged  and  filled  with  epithelium,  blood  cor- 
puscles, and  fibrin.  The  capsule  is  easily  detached,  and  is 
more  opaque  than  normal.  If  the  termination  is  favorable  the 
swelling  lessens,  the  vascularity  diminishes,  and  the  tubules 
gradually   return   to   their  normal   condition. 

Symptoms. — In  mild  cases,  slowly  developing  dropsy  with 
anemia,  shortness  of  breath  or  dyspnea,  and  weakness  are 
the  only  symptoms,  the  diagnosis  being  confirmed  by  the 
results  of  urinary  examination.  Usually,  however,  it  begins 
suddenly  with  nausea,  violent  and  persistent  vomiting,  fever, 
and  dull  pain  over  the  kidneys,  following  the  course  of  the 
ureters.  There  is  a  frequent  desire  to  urinate,  and  diarrhea, 
harsh  and  dry  skin,  and  a  quick,  tense,  and  full  pulse  are  present. 
Dropsy  soon  appears,  beginning  first  in  the  eyelids  and 
face,  but  later  becoming  generalized.  Anemia  and  weakness 
are  marked  particularly  in  post-scarlatinal  cases.  Uremic 
symptoms  may  develop  at  any  time  during  the  attack.  The 
affection  lasts  from  one  to  four  weeks. 

The  urine  is  of  high  specific  gravity,   1025  to   1030,  scanty. 


ACUTE    PARENCHYMATOUS    NEPHRITIS.  353 

smoky  (like  beef  washings)  in  color,  due  to  the  presence  of 
blood.  Albumin  is  present-  in  large  quantities,  and  the  mi- 
croscope reveals  hyaline,  blood,  granular,  and  epithelial  casts 
of  the  uriniferous  tubules,  blood  corpuscles,  uric  acid,  urates, 
oxalate  crystals,  and  epithelium.  The  total  amount  of  urea 
eliminated  during  the  twenty-four  hours  is  lessened  from  one- 
fourth  to  one-half.  The  amount  of  phosphates  and  chlorids 
is   also  lessened. 

Complications. — Pericarditis,  pleurisy,  pneumonia,  perit- 
onitis,   and  uremia  are    the  principal  complications. 

Diagnosis. — The  diagnostic  features  of  this  disease  are  its 
history,  the  age  at  which  it  occurs,  the  sudden  onset,  the 
dropsy,  and  the  urine  which  is  scanty,  smoky,  and  of  high 
specific  gravity,  containing  albumin,  diminished  quantity  of 
urea,  tube-casts  (hyaline,  blood,  epithelium,  and  dark  gran- 
ular   casts),    blood    cells,    epithelium,    and    granular    cells. 

Prognosis. — The  prognosis  is  generally  favorable,  recovery 
occurring  in  most  cases  under  prompt  and  appropriate  treat- 
ment. Uremia  may,  however,  occur  in  the  course  of  the  disease 
and  lead  to  a  fatal  termination.  Pulmonary  edema,  purulent 
exudations  into  the  serous  cavities,  and  exhaustion,  may 
intervene  and  produce  death.  The  affection  may  pass  into 
chronic  nephritis. 

Treatment. — The  patient  should  be  placed  at  rest  in  bed 
until  all  the  symptoms  have  disappeared.  A  strictly  milk 
diet  is  most  suitable,  but  if  the  depression  and  weakness  are 
marked,  animal  broths,  and  even  oysters  may  be  allowed. 
Tea,  coffee,  beef -tea  extracts,  and  stimulants  should  be  inter- 
dicted. Water  or  cream  of  tartar  lemonade  may  be  freely 
used  for  its  diuretic  effect.  Dry  cups  should  be  applied  over 
the  kidneys,  followed  by  digitalis  or  jaborandi  poultices,  using 
equal  parts  of  flaxseed  and  the  leaves  of  digitalis  or  jaborandi. 
The  bowels  should  be  kept  freely  opened  by  means  of  the 
saline  cathartics,  compound  jalap  powder,  oi  (4  gm.),  in 
water  before  breakfast,  or  elaterium,  gr.-  1/6  (0.0 11  gm.), 
repeated  as  the  occasion  requires.  Combined  with  these 
procedures  there  should  be  free  sweating  or  diaphoresis. 
23 


354         .  ACUTE    PARENCHYMATOUS    NEPHRITIS. 

This  is  best  obtained  by  the  use  of  the  hot-air  bath,  the  hot 
pack,  or  the  wet  sheet  and  blanket  bath,  stimiilating  the  per- 
ipheral circulation  after  free  sweating  has  occurred  by  rubbing 
with  alcohol  and  water.  Drugs  may  be  administered  coin- 
cidently  to  aid  the  sweating  process.  Spirit  of  nitrous  ether, 
nxv  to  XXX  (0.3  to  2  C.C.),  fluidextract  of  pilocarpin,  rnv  to 
XXX  (0.3  to  2  c.c),  every  three  or  four  hours,  pilocarpin  hydro- 
chlorid,  gr.  1/6  (o.oii  gm.),  hypodermically,  as  the  occasion 
requires,  or  the  wine  of  ipecac,  nxi  to  iii  (0.06  to  0.2  c.c), 
every  half-hour  may  be  used  for  this  purpose.  Diuretics, 
such  as  digitalis,  digitalin,  gr.  i/ioo  (0.00065  g^^-)>  citrated 
caffein,  gr.  ii  to  iv  (0.13  to  0.26  gm.),  or  spartein  sulphate, 
gr.  1/3  to  1/2  (0.02  to  0.03  gm.)  should  be  employed.  The 
following  formula  (Millard)  is  suitable  in  the  majority  of 
cases : 

I^.      Tinct.  digitalis f  5ss  15.   c.c. 

Aceti   scillse f  giss  45.  c.c. 

Spt.  setheris  nitrosi foij  60.  c.c. 

M.  S. — Teaspoonful  every  two  to  four  hours,  in  water. 

The  following  combination  has  also  given  excellent  results: 

I^.      Potassii  acetat oiv  15 .  gm. 

Inf.  digital f  5iij  90.  c.c. 

Liq.  potassii  citratis  ....    f  §iij  90.  c.c. 

M.  S. — Tablespoonful  every  two  to  four  hours,  in  water. 

Tyson  strongly  urges  the  use  of  infusion  of  digitalis  instead 
of  the  tincture.  He  also  recommends,  as  an  admirable  diu- 
retic combination.    Trousseau's  diuretic  wine,  viz.: 

I^.      Junip.  contus ox  40.  gm. 

Pulv.  digitalis 3ij  8.  gm. 

Pulv.  scillse 3  j  4  •  gm. 

Vin.  xerici Oj  480.  c.c. 

Macerate  for  four  days  and  add 

Potassii  acetatis 3iij  12  .  gm. 

Express  and  filter. 

S. — Tablespoonful  three  times  a  day  for  an  adult. 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  355 

The  onset  of  uremia  (page  373)  calls  for  special    treatment. 

As  soon  as  the  blood  disappears  from  the  urine  some  prep- 
aration of  iron,  preferably  Basham's  mixture,  should  be  ad- 
ministered until  the  health  is  entirely  restored.  The  addi- 
tion of  I  minim  (0.065  c.c.)  of  spirit  of  nitroglycerin  to  each 
dose  of  Basham's  mixture  increases  its  efficiency. 

I^.      Liq.  ammon.  acetat fovj  180.  c.c. 

Acid,  acetic f  oiij  12.  c.c. 

Tinct.  ferri  chlor fov  20.  c.c. 

Alcoholis f  §ij  60.  c.c. 

Syrup f  5iv  120.  c.c. 

Aquae f  oiv  120.  c.c. 

M.    S. — Basham's    mixture.      Dose    i    dram    to    i    ounce, 
diluted. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Synonyms. — Chronic  Bright's  disease;  chronic  croupous 
nephritis;  chronic  tubal  nephritis;  chronic  albuminuria;  large 
white  kidney. 

Definition. — A  chronic  inflammation  of  the  cortical  tubular 
structure  of  the  kidneys;  characterized  by  albuminous  urine, 
dropsy,   and  increasing  anemia,   with  attacks  of  acute  uremia. 

Causes. — It  rarely  follows  an  acute  attack;  in  the  majority 
of  cases  it  is  subacute  or  chronic  from  the  onset.  It  is  a  dis- 
ease of  young  adults,  especially  males,  and  is  seldom  observed 
after  forty  years  of  age.  Habitual  exposure  to  cold  and  wet, 
malaria,  syphilis,  alcoholic  excesses,  chronic  mercurialism, 
lead-poisoning,  opium  habit,  protracted  suppuration,  phthi- 
sis, hepatic  disorders,  pregnancy,  and  some  undetermined 
nervous,  condition  are  the  principal  causes. 

Pathologic  Anatomy. — The  kidney  is  large,  often  twice  its 
natural  size,  smooth,  and  white  or  yellowish  white  in  color. 
The  capsule  is  nowhere  adherent  to  the  organ.  Upon  section, 
considerable  tumefaction  of  the  cortical  substance  and  rarity 
of   vascular   striae    are   recognized.     The    medullary   substance 


356  CHRONIC    PARENCHYMATOUS    NEPHRITIS. 

shows  no  appreciable  alteration,  its  color  being  normal.  The 
convoluted  tubes  are  irregularly  dilated  and  thickened,  and 
filled  with  broken-down  granulated  epithelium  and  fibrinous 
casts.  In  pronounced  cases  there  is  fatty  degeneration  of  the 
tubular  epithelium.  The  intertubular  matrix  is  greatly  thick- 
ened— a  change  due  to  hyperplasia  of  the  connective-tissue 
elements,  to  the  migration  of  the  white  corpuscles  and  their 
subsequent  multiplication  and  fatty  transformation,  and  to 
a  quantity  of  fluid  exudation,  the  product  of  the  increased 
pressure  in  the  veins.  As  the  affection  progresses  the  con- 
nective tissue  tends  to  undergo  contraction,  and  the  organ 
becomes  pale  and  reduced  in  size,  the  capsule  becomes  more 
or  less  adherent,  and  the  surface  of  the  kidney  becomes  un- 
even. During  this  contracting  stage  small  hemorrhages  may 
appear,  scattered  throughout  the  cortex. 

Symptoms. — The  onset  of  the  disease  is  gradual  and  insid- 
ious, being  marked  by  a  period  of  ill-health,  anemia,  digestive 
disturbances,  weakness,  puffiness  under  the  eyes,  most  no- 
ticeable   in    the    morning,    dyspnea,    cardiac   palpitation,    etc. 

Vomiting,  without  apparent  cause,  headache,  vertigo, 
defective  vision,  and  more  or  less  generalized  dropsy  are 
also  symptoms.  Transient  blindness  is  not  uncommon  in 
the  early  stages,  but  late  in  its  course  permanent  loss  of  vis- 
ion may  occur,  due  to  retinal  disease.  Hypertrophy  of  the 
heart,  with  high  arterial  tension  and  accentuation  of  the 
aortic  second  sound  are  common  accompaniments.  Bron- 
chial catarrh,  with  edema  of  the  larynx,  may  also  develop. 
Anemia  is  pronounced  on  account  of  the  large  loss  of  albumin 
and  gastrointestinal  disorders,  and  neuralgic  pains  are  com- 
mon. Uremic  asthma  and  other  manifestations  of  uremia 
may  present  themselves  at  any  time.  Irritability  of  the 
bladder  is  a  very  constant  symptom,  occurring  very  early  in 
the  course  of  the  disease. 

The  Urine. — The  urine  is  scanty,  high-colored,  albumin- 
ous, and  under  the  microscope  shows  hyaline  and  granular 
tube-casts,  granular  epithelium,  and  if  fatty  degeneration 
occur,  fatty  tube  casts  and  oil  globules.     The  increase  above 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  357 

the  normal  amount  of  the  urine,  as  the  disease  progresses, 
must  not  be  forgotten  when  the  specific  gravity  is  low,  i.oio 
-0.015,  ^i^d.  the  quantity  of  albumin  is  increased.  The  normal 
constituents  of  the  urine,  and  particularly  urea  are  diminished. 
In   the  hemorrhagic  form,   blood   is   present   in  the  urine. 

Complications. — Uremia,  edema  of  the  lungs,  pneumonia, 
pleurisy,  pericarditis,  peritonitis,  meningitis,  cardiac  hyper- 
trophy,   and    apoplexy    are    the    most    common    complications. 

Prognosis. — Complete  recovery  never  occurs.  Well-marked 
cases  may  terminate  in  death  within  a  few  months  or  two 
years,  while  milder  cases  under  appropriate  treatment  may 
be  prolonged  for  an  indefinite  period.  The  appearance  of 
complications  and  acute  exacerbations  are  of  unfavorable 
significance.  The  presence,  persistently,  of  fatty  tube-casts 
and  oil  globules  in  the  urine  is  likewise  unfavorable.  The 
secondary  contraction  of  the  kidneys  must  always  be  kept 
in  mind,  the  particular  symptoms  of  which  are  increased  fiow 
of  urine  of  low  specific  gravity,  with  small  amount  of  al- 
bumin, and  hypertrophy  of  left  ventricle,  with  accentuated 
aortic  second  sound.  It  is  to  be  borne  in  mind  that  the 
course  of  a  case  of  chronic  Bright' s  disease  is  not  continously 
downward;  periods  of  remission  often  follow  the  most  aggra- 
vated symptoms,  the  patient  and  his  friends  being  buoyed  with 
the  hope  of  an  early  recovery,  when,  suddenly,  an  attack  of 
acute  uremia  terminates  life. 

Treatment. — Rest  is  the  first  indication  in  the  treatment. 
Residence  in  a  dry  and  warm  climate  is  a  very  useful  adjunct. 
Woolen  underclothing  should  be  worn.  The  diet  is  of  prime 
importance  and  should  be  so  arranged  as  to  reduce  the  quan- 
tity of  nitrogenous  foods  to  a  minimum.  It  may  consist  of 
an  absolute  milk  regimen,  pure,  or  prepared  as  most  palat- 
able, or  an  exclusive  lean  meat  diet,  prepared  by  finely  chop- 
ping, removing  all  fibrous  and  fatty  portions,  boiled  quickly, 
salted  to  taste,  and  served  hot — the  so-called  "  Salisbury 
steaks."  The  use  of  half  a  pint  of  hot  water,  acidulated  with 
lemon,  before  each  meal  is  valuable. 

The  elimination  of  the  effete  matters,  retained  in  the  blood 


358  CHRONIC    PARENCHYMATOUS    NEPHRITIS. 

by  reason  of  the  crippled  condition  of  the  kidneys,  may  be 
brought  about  by  catharsis,  diuresis,  and  diaphoresis.  The 
use  of  cathartics  aids  in  reducing  any  existing  edema  and 
prevents  to  some  extent  the  onset  of  uremia.  The  following 
is  of  value  when  the  urine  is  scanty  and  the  bowels  are  costive: 

I^.      Hydrarg3n:i  chlor.  mitis,  . 

Pulv.  scill^, 

Pulv.  digital; aa  gr.  j  aa  .065.  gm. 

M.     Ft.  pil.  No.  i. 

S. — To  be  taken  three  times  daily. 

Excessive  dropsy  will  call  for  the  administration  of  com- 
pound jalap  powder,  magnesium  sulphate,  elaterium,  or 
the  alkaline  mineral  waters  combined  with  free  diaphoresis. 
Diuretics  are  of  value  when  the  urine  is  scant,  the  most  useful 
of  which  are  digitalis,  citrated  caffein,  spartein  sulphate,  nitro- 
glycerin, potassium  citrate,  diuretin,  and  water.  Dry  cups 
or  poultices  over  the  loins,  and  the  injection  of  normal  salt 
solution  into  the  bowels  or  beneath  the  skin  have  diuretic  prop- 
erties. Diaphoresis  may  be  brought  about  by  the  use  of  the 
warm  bath,  the  Turkish  bath,  the  warm  pack,  and  vapor  or 
hot-air  bath  together  with  friction  and  the  administration 
of  pilocarpin  in  some  form.  The  following  ointment  is  ex- 
tremely valuable: 

I^.     Pilocarpinae  nitrat gr.  j  to  iij    .  065  to  2  gm. 

Petrolati oj  30.  gm. 

M.  S. — Apply  a  piece  the  size  of  a  hickory-nut  over  the 
dor  so-lumbar  regions,  night  and  morning,  covering  the  sur- 
face with  a  layer  of  cotton  or  gauze.  ,  ,  ^ 

The  anemia  requires  the  administration  of  some  prepa- 
ration of  iron,  the  best  of  which  for  this  condition  is  Basham's 
mixture  on  account  of  its  diuretic  properties.  The  addition 
of  the  spirit  of  nitroglycerin  adds  to  its  efficacy.  Cod-liver 
oil  and  arsenic  are  also  of  benefit.  Drugs  such  as  ergot, 
quinin,   gallic  acid,   sodium  benzoate,   tincture  of  cantharides, 


CHRONIC    INTERSTITIAL    NEPHRITIS.  359 

and  potassium  iodid  are  believed  to  exercise  an  influence  in 
checking  the  waste  of  albumin  and  are  sometimes  employed. 

When  the  dropsy  becomes  marked  the  various  measures 
already  mentioned  should  be  freely  employed  and  often  it 
will  be  necessary  to  resort  to  tapping  and  to  multiple  punc- 
tures of  the  skin.  Uremia  {q.v.)  will  demand  special  treat- 
ment. 

Surgical  Treatment. — Edebohls  proposed  and  employed 
decapsulation  or  decortication  of  the  kidney  in  this  disease 
with  encouraging  results. 

CHRONIC  INTERSTITIAL  NEPHRITIS. 

Synonym.s. — Chronic  Bright's  disease;  sclerosis  of  the  kid- 
ney; contracted  kidney;  cirrhotic  kidney;  granular  kidney; 
small    red    kidney;  gouty  kidney. 

Definition. — An  inflammation  of  the  intervening  connect- 
ive, tissue  of  the  kidney,  chronic  in  its  progress,  resulting  in 
an  induration  or  hardening,  with  contraction  of  the  organ; 
characterized  by  the  frequent  voiding  of  large  amounts  of 
pale,  albuminous  urine,  of  low  specific  gravity,  disorders  of 
the  gastrointestinal  canal  and  nervous  system,  and  a  strong 
tendency  to  cardiac  hypertrophy  and  changes  in  the  vessels. 
Albuminuria  may  be  absent. 

Causes. — The  disease  occurs  usually  in  males  from  forty 
to  sixty  years  of  age.  It  may  be  primary,  or  secondary  to 
chronic  parenchymatous  nephritis.  Gout,  chronic  lead-poi- 
soning, syphilis,  alcoholism,  opium  habit,  chronic  cystitis, 
chronic  gonorrhea,  long-continued  worry,  anxiety  or  grief, 
alterations  in  the  renal  ganglionic  centers,  hereditary  influ- 
ences, passive  congestion  from  heart-disease,  and  hepatic 
disorders  are  the  principal  causes. 

Pathologic  Anatomy. —  Both  kidneys  are  usually  involved 
and  their  size  is  diminished.  The  capsule  is  thickened, 
opaque,  and  adherent.  The  surface  of  the  kidney  is  granular, 
with  cysts  of  various  sizes,  of  transparent  color,  scattered 
irregularly   over   the    surface.      On   section,    the   tissue   of   the 


360  CHRONIC    INTERSTITIAL    NEPHRITIS. 

kidney  is  tough  and  resistant.  The  cortical  portion  is  thin 
from  atrophy,  being  only  a  line  or  two  in  thickness.  The 
connective  tissue  is  greatly  thickened,  compressing  the  tu- 
bules into  mere  threads,  the  glomeruli  being  grouped  together 
in  bunches,  owing  to  the  wasting  of  the  intermediate  tubes. 
The  color  varies  from  a  dark  brown  to  a  yellowish  gray,  ac- 
cording  to   the   amount   of   blood   in   the   organ. 

The  left  side  of  the  heart  is  hypertrophied,  and  there  is  also 
hypertrophy  of  the  muscular  fiber  of  the  arterioles  through- 
out the  body;  if  the  case  is  protracted,  the  hypertrophied 
tissues  undergo  fatty  degeneration.  Cardiac  degeneration 
with  arteriocapillary  sclerosis  or  fibrosis  is  associated  with 
advanced  nephritis.  The  changes  in  the  arterial  walls  lead 
to  apoplexy,  albuminuric  retinitis,  and  fatty  degeneration 
and  atrophy  of  the  ganglionic  centers. 

According  to  Tyson,  the  kidney  may  be  atrophic  and  possess 
an  excess  of  connective  tissue  as  the  result  of  senility,  inde- 
pendent of  chronic  interstitial  nephritis. 

Symptoms. — The  onset  is  insidious,  and  often  marked  alter- 
ations in  the  kidneys,  heart,  and  vessels  have  occurred  before 
the  disease  is  recognized.  There  are  no  characteristic  early 
symptoms  in  the  majority  of  cases,  the  disease  being  apparently 
latent  until  some  special  outbreak  causes  a  more  thorough 
examination  of  the  patient,  when  interstitial  nephritis  is 
detected. 

Any  of  the  following  symptoms  may  first  attract  attention 
frequent  micturition;  increased  amount  of  acid  urine,  50  to 
90  ounces,  and  of  a  pale  color;  low  specific  gravity,  1,005  "^o 
1,015;  containing  a  small  amount  of  albumin,  which  maybe 
absent  for  days;  occasional  epithelial  cells  and  hyaline  and 
pale  granular  casts.  No  dropsy,  but  a  little  puffiness  and 
edema  of  the  conjunctiva — the  Bright's  eye.  Subconjunc- 
tival ecchymoses.  Disorders  of  vision.  Albuminuric  ret- 
initis. Forcible  cardiac  action  with  high  arterial  tension, 
due  to  left  cardiac  hypertrophy,  which  is  an  almost  constant 
condition.  Attacks  of  vertigo;  headache;  pulsations  in  the 
neck,  and  other  parts  of  the  body,  and,  as  the  disease  progresses. 


CHRONIC    INTERSTITIAL    NEPHRITIS.  36 1 

cardiac  distress,  dyspnea,  and  jjalpitation  occur.  A  redu- 
plication of  the  first  cardiac  sound  is  common;  the  second 
aortic  sound  is  accentuated  and  the  pulse  is  hard  and  resist- 
ing,   indicating    high    tension    and    thickening. 

Progressive  anemia  is  a  frequent  symptom.  There  is 
great  weakness;  the  body  weight  declines;  the  skin  is  dry 
and  scurfy;  and  there  is  shortness  of  breath  on  exertion.'  Al- 
bumin may  be  constantly  absent  from  the  urine,  and  casts 
be  only  occasionally  detected  after  many  trials  and  yet  the 
disease  will  progress  toward  a  fatal  termination.  Toward 
the  end,  the  urine  diminishes  in  quantity,  the  specific  gravity 
increases,  and  the  casts  become  more  numerous  and  various, 
dark  granular  and  blood  casts  often  being  observed.  Uremia 
may  occur  at  any  time  and  may  be  manifested  by  persistent 
dyspepsia,  occasional  vomiting,  headache,  vertigo,  stupor, 
drowsiness,  violent  itching  of  the  skin,  tremors,  convulsions, 
epileptic  seizures,  or  apoplectic  attacks.  The  duration  is 
indefinite  and  the  termination  is  usually  in  death  by  convul- 
sions and  coma. 

Complications. —  Bronchitis,  pneumonia,  pleurisy,  pericar- 
ditis, cardiac  hypertrophy,  uremia,  albuminuric  retinitis,  and 
apoplexy,  are  the  most  common  complications. 

Diagnosis. — Interstitial  nephritis  is  most  likely  to  be  con- 
founded with  parenchymatous  nephritis.  The  following  table 
from  Wheeler  and  Jack  presents  the  most  important  points 
of  difference  between  the  various    forms    of    Bright's  disease: 


362 


CHRONIC    INTERSTITIAL    NEPHRITIS. 


00        o        Q 


t3 


CHRONIC    INTERSTITIAL    NEPHRITIS. 


Z^Z 


It  is  important,  also,  to  distinguish  between:  (i)  interstitial 
nephritis  with  secondary  arterial  sclerosis,  and  (2)  general 
arterial  sclerosis  with  secondary  contracted  kidney.  Tyson 
thus  tabulates  the  differences  between  these  two  conditions: 


Primary   Chronic   Interstitial 
Nephritis. 


1 .  Causes  of  chronic  intersitial  neph- 
ritis, such  as  overeating  and 
drinking,  gout,  diabetes,  syphilis, 
lead  intoxication,  etc. 

2.  Characteristic  insidious  onset,  in- 
cluding digestive  derangements, 
small  albuminuria,  few  casts, 
with  little  or  no  evidence  of 
arterial  change  at  first. 

3.  Edema,  never  at  first,  later 
unusual. 

4.  Arterial  pulsation  often  very 
annoying. 

5.  Vertigo  infrequent .  .  . 

6.  Albuminuric  retinitis  and  hemor- 
rhages into  retina. 

7.  Hypertrophy  of  one  or  both  ven- 
tricles rather  more  frequent,  say 
42  per  cent. 

8.  High  blood-pressure  and  high 
arterial  tension  before  vascular 
change  is  evident. 

9.  True  uremia 


Primary  General  Arterio- 
sclerosis. 


I.   Same  causes. 


Early  appearance  of  arterial 
changfes. 


3.  Edema  frequent  and  often 
marked. 

4.  No  pulsation  in  head  or 
elsewhere. 

5.  Vertigo  common. 

6.  Retinal  changes,  but  not 
hemorrhage,  nor  retinitis 
albuminurica. 

7.  Rather  less  frequent,  say 
36  per  cent. 

8.  Moderate  or  lowered  blood- 
pressure,  moderate  arterial 
tension. 

Q.   Simulated  uremia. 


Prognosis. — Recovery  never  occurs.  The  disease  is  essen- 
tially chronic ;  cases  have  lasted  as  long  as  eleven  years.  Uremic 
symptoms  are  of  unfavorable  significance. 

Treatment. — The  diet  should  be  carefully  regulated  and  ni- 
trogenous foods  should  be  eliminated.      Milk  (plain,  skimmed. 


364  AMYLOID    KIDNEY. 

or  diluted  with  Vichy),  eggs  (soft-boiled  or  poached  in  milk), 
chicken  broth,  and  vegetables  should  constitute  the  larger 
portion  of  the  food.  Alcoholic  stimulants  should  be  avoided. 
Physical  and  mental  rest  should  be  advised.  A  daily  warm 
or  hot  bath  is  valuable  but  under  no  consideration  should  cold 
or  sea-bathing  be  allowed.  Warm  clothing  should  be  worn 
and  the  body  should  be  protected  from  cold  and  dampness. 
Regularity  in  the  bowel  movements  is  desirable  and  for  this 
purpose  the  alkaline  mineral  waters,  the  salines,  or  cascara 
sagrada  should  be  administered.  Iron  will  be  necessary  to 
combat  the  anemia  and  potassium  iodid  may  be  of  value  in 
lessening  the  connective-tissue  hypertrophy.  Headache,  vertigo, 
and  similar  symptoms  dependent  upon  increased  arterial  ten- 
sion may  be  relieved  by  the  use  of  spirits  of  nitroglycerin,  nxi 
(0.06  c.c),  or  nitroglycerin,  gr.  i/ioo  (0.00065  gm.),  three 
times  daily.  Opium  or  any  of  its  preparations  should  never 
be  employed.  When  a  hypnotic  is  required,  sulfonal,  trional, 
or  paraldehyde  should  be  used.  In  the  early  stages  of  the 
disease    the   following   formula   will   be   found   very   valuable: 

I^.      Hydrargyri  chloridi  corrosiv  gr.  j  .065  gm. 

Auri  et  sodii  chloridi gr.  j  .065  gm. 

Ferri  reduct gr.  xxx  2 .          gm. 

Spts.  glonoini tt^xxx  2 .          c.c. 

M.      Ft.  pil.  No.  xxx. 
S. — One  after  meals. 

For  gastric  symptoms  the  following  is  an  excellent  formula: 

I^.      Pepsin,   pur gr.  xxxij  2 .  gm. 

Acidi  hydrochloric,  dil.  .    foss  15.  c.c. 

Glycerini f5j  30.  c.c. 

Aquae  chloroformi.  q.  s.  ad  f  5iij  90  .  c.c. 

M.  S. — One  teaspoonful  at  mealtime,  well  diluted. 

AMYLOID  KIDNEY. 

Synonyms. — Chronic  Bright's  disease;  waxy  kidney;  larda- 
ceous  kidney. 

Definition. — A  peculiar  infiltration  into  the  structure  of  the 
kidney,  from  the  deposit  of  an  albuminoid  material,  having  a 


AMYLOID    KIDNP:Y.  365 

superficial  resemblance  to  molten  wax  or  boiled  starch,  and  which 
strikes  a  deep  mahogany-red  color  when  treated  with  a  solution 
of  iodin.  Similar  changes  occur  in  the  liver,  spleen,  intestines, 
and  other  organs. 

Causes. — The  chief  causes  are  prolonged  suppuration,  espe- 
cially of  the  bones;  coxalgia;  syphilis;  cancer;  phthisis. 

Pathologic  Anatomy. — The  kidney  is  uniformly  enlarged.  It 
presents  a  pale,  glistening,  translucent  appearance,  and  has  a 
doughy  consistency.  On  section,  the  surface  is  homogeneous, 
anemic,  and  whitish.  The  deposit  occurs  along  the  renal  vessels 
and  in  the  vascular  tufts  of  the  glomeruli,  progressing  until  all 
parts  of  the  organ  are  infiltrated.  When  the  organ  is  thus  in- 
filtrated, the  structure  proper  undergoes  an  atrophic  degenera- 
tion, the  result  of  pressure. 

The  reaction  with  iodin  and  sulphuric  acid  affords  a  certain 
test  for  the  amyloid  deposit.  Brush  over  a  section  of  the 
affected  kidney  a  solution  of  iodin  with  iodid  of  potassium  in 
water,  when  a  mahogany  color  will  be  produced,  and  if  diluted 
sulphuric  acid  is  now  added  a  violet  or  bluish  tint  results. 
A  very  pretty  reaction  is  made  by  contact  with  a  i  per  cent,  solu- 
tion of  anilin  violet,  which  strikes  a  red  or  pink  color  with  the 
amyloid  material,  while  the  unaltered  tissues  are  stained  blue, 
making  a  beautiful  contrast. 

Similar  changes  occur  in  other  organs  of  the  body.  With  the 
amyloid  change  *may  be  associated  either  parenchymatous  or 
interstitial  nephritis. 

Symptoms. — Together  with  the  symptoms  of  the  underlying 
causes  there  are  edema  of  the  lower  extremities,  ascites,  in- 
creased fiow  of  pale  watery  urine  of  low  specific  gravity  contain- 
ing albumin  and  hyaline  and  waxy  tube-casts,  and  sometimes 
diarrhea.  The  liver  and  spleen  are  enlarged.  Uremia,  cardiac 
hypertrophy,  or  increased  arterial  tension  are  extremely  rare 
in  this  disease  unless  other  forms  of  nephritis  are  present  coin- 
cidently. 

Diagnosis. — The  history  of  prolonged  suppuration,  the  en- 
largement of  the  liver  and  spleen,  and  the  increased  flow 
of  pale  urine   containing   waxy   casts   which   give   the  amyloid 


366  PYELITIS. 

reaction,  serve  to  distinguish  this  disease  from  other  renal 
affections. 

Prognosis. — If  the  underlying  disease  can  be  cured  before  the 
amyloid  change  has  been  fully  developed  it  may  be  arrested; 
otherwise  a  fatal  termination  may  be  expected  in  from  a  few 
months  to  a  year. 

Treatment. — In  addition  to  measures  directed  toward  the 
primary  cause,  every  effort  should  be  made  to  sustain  the 
patient.  For  this  purpose  a  generous  diet,  syrup  of  iodid  of 
iron,  cod-liver  oil,  quinin,  ammonium  chlorid,  etc.,  should  be 
freely  administered.  In  cases  due  to  syphilis,  potassium  iodid 
and  small  doses  of  bichlorid  of  mercury,  gr.  1/50  to  1/25 
(0.0015  to  0.003  gm.),  should  be  given  over  an  extended  period. 

PYELITIS. 

Synonyms. — Suppurative  nephritis;  pyelo-nephritis ;  surgical 
kidney. 

Definition. — An  acute  catarrhal  inflammation  of  the  pelvis  of 
the  kidney;  the  term  pyelo-nephritis  is  used  when  suppurative 
inflammation  is  superadded  to  the  catarrhal  inflammation. 
The  disease  is  characterized  by  lumbar  pains,  irritability  of  the 
bladder,  the  urine  being  neutral  or  alkaline  in  reaction  and  milky 
in  appearance;  if  pyelo-nephritis  occurs  symptoms  of  hectic 
fever  and  exhaustion  are  added,  the  urine  containing  pus. 

Causes. — Cold  or  exposure ;  cystitis ;  obstruction  of  the  ureters 
by  renal  calculi ;  pressure  from  a  tumor ;  prolonged  use  of  bromids 
and  other  irritative  drugs;  rheumatism;  and  infectious  diseases. 

Pathologic  Anatomy. — The  inflammation  is  at  first  catarrhal; 
it  is  characterized  by  injection  of  the  mucous  membrane  of  the 
pelvis  of  the  kidney,  with  slight  extravasations  of  blood;  relaxa- 
tion and  softening,  shedding  of  the  epithelium,  and  the  subse- 
quent discharge  of  mucus  and  pus.  If  the  morbid  condition 
has  existed  for  some  time,  the  kidneys,  one  or  both,  are  in  a 
process  of  suppuration;  they  are  enlarged,  deeply  congested, 
except  where  suppuration  is  proceeding,  when  they  are  of  a 
yellowish -white  color — pyelo-nephritis.     Pus  is  constantly  form- 


PYELITIS.  '  367 

ing  and,  if  there  be  no  obstruction,  flows  away  with  the 
urine;  should  there  be  an  impediment  to  its  escape,  pus  accumu- 
lates in  the  pelvis  of  the  kidney,  causing  its  distention,  giving 
rise  to  the  condition  known  as  pyelo-nephrosis.  The  pressure 
caused  by  the  obstruction  finally  leads  to  destruction  of  the 
entire  organ,  a  mere  sac,  or  renal  cyst,  remaining. 

Symptoms. — The  affection  begins  with  chilliness,  feverish- 
ness,  lumbar  pains  following  the  course  of  the  ureters,  and 
frequent  micturition.  The  urine  is  milky  in  appearance  when 
voided,  acid  or  neutral  in  reaction,  and  deposits  a  copious 
whitish  or  yellowish  white  sediment  containing  a  small  amount 
of  albumin.  Blood  will  be  present  if  the  condition  is  due  to  a 
renal  calculus.  The  formation  of  pus  is  indicated  by  chills, 
irregular  fever,  sweats,  localized  pain,  enlargement,  and  ten- 
derness in  lumbar  region,  the  presence  of  pus  in  the  urine,  and 
leukocytosis.  In  marked  cases  there  are  low  muttering  delir- 
ium, fissured  and  dry  tongue,  anemia,  emaciation,  stupor,  and 
coma.      If  both  kidneys  are  involved  uremia  may  supervene. 

Diagnosis. — Cystitis  may  be  distinguished  by  its  history,  the 
absence   of  lumbar  pains,  and  the  alkaline  urine. 

Perinephritic  abscess  or  suppuration  of  the  loose  cellular  tissue 
surrounding  the  kidney,  is  characterized  by  localized  pain, 
swelling,  tenderness,  and  edema  in  the  lumbar  region  with 
chills,  fever,  and  sweat,  but  the  urine  remains  normal. 

Renal  calculus  may  give  rise  to  pyelitis  and  in  such  cases 
renal  colic,  the  passage  of  the  stone,  and  the  presence  of  blood 
in  the  urine  will  aid  in  making  the  diagnosis. 

Tuberculosis  of  the  pelvis  of  the  kidney  has  many  points  in 
com.mon  with  simple  pyelitis,  but  in  the  former  there  are  in 
addition  tuberculous  foci  elsewhere  in  the  body  and  tubercle 
bacilli  may  be  found  in  the  urine. 

Prognosis. — Simple  catarrhal  cases  in  which  there  is  no 
obstruction  to  the  discharge  usually  recover.  In  the  presence 
of  an  obstruction  or  suppuration  the  prognosis  is  unfavorable. 

Treatment. — Rest  in  bed  and  a  milk  diet  are  essential.  Free 
diaphoresis  and  the  free  consumption  of  water  to  dilute  the 
urine  are  indicated.      Local  applications  of  heat  to  the  lumbar 


368  NEPHRO-LITHIASIS. 

region  and  the  use  of  opium  will  be  required  to  relieve  the  pain. 
The  character  of  the  renal  secretion  may  be  altered  by  the 
administration  of  tar,  santal  wood  oil,  copaiba,  eucalyptol, 
turpentine,  cubebs,  benzoic  acid,  salol,  or  urotropin.  Of  these 
benzoic  acid,  5  gr.  (0.33  gm.),  may  be  given  in  capsules  four 
times  a  day;  or  urotropin  also  in  capsules,  and  in  similar  dose, 
and  preferably  on  an  empty  stomach.  If  there  is  renal 
hemorrhage  alum,  gr.  xx  (1.3  gm.),  may  be  used.  The  rapid 
exhaustion  calls  for  the  use  of  tonics,  particularly  quinin, 
strychnin,  iron,  etc.  As  suppuration  is  likely  to  supervene 
at  any  time,  a  surgeon  should  be  consulted  early  as  a  prompt 
operation  may  be  the  means  of  saving  otherwise  hopeless  cases. 

NEPHRO-LITHIASIS. 

Synonyms. — Renal  calculus;  gravel;  renal  colic;  stone  in  the 
kidney. 

Definition. — Renal  calculi  are  concretions  formed  by  the  pre- 
cipitation of  certain  substances  from  the  urine,  around  some 
body  or  substance  acting  as  a  nucleus. 

Their  presence  may  not  be  recognized  until  one  or  more  at- 
tempt to  pass  along  the  ureters,  when  an  attack  of  renal  colic 
results;  or,  by  irritation  pyelitis  is  produced;  or,  more  rarely, 
they  are  voided  by  the  urine  without  exciting  any  symptoms. 
By  gravel  is  meant  very  small  concretions  (sand),  which  are 
often  passed  in  the  urine  in  large  numbers. 

Causes. — The  affection  occurs  at  all  ages,  but  is  most  common 
in  individuals  from  forty  to  fifty  years  of  age.  A  special  lia- 
bility seems  to  exist  in  some  families  but  the  precise  etiology  of 
nephro-lithiasis  is  as  yet  undetermined. 

Characteristics. — In  structure  a  urinary  calculus  consists  of  a 
central  nucleus  surrounded  by  a  body,  outside  of  which  there 
may  be  a  phosphatic  crust.  The  nucleus  may  or  may  not  be 
of  the  same  material  as  the  rest  of  the  stone,  sometimes  being 
a  foreign  body,  or  inspissated  mucus  or  blood.  On  section  the 
stone  shows  a  stratified  arrangement,  often  radiated.  They 
occur  iti  several  varieties: 


NEPHRO-LITHIASIS.  369 

1.  Uric  acid,  as  calculi  and  gravel,  and  especially  associated 
with  the  gouty  diathesis. 

2.  Urates,  chiefly  urate  of  ammonium;  nearly  always  in 
childhood. 

3.  Oxalate  of  lime  or  mulberry  calculus;  characterized  by 
hardness,  roughness,  and  very  dark  color. 

4.  Phosphatic  calculi  form  as  frequently  in  the  bladder  as  in 
the  kidney,  and  present  a  chalky  or  earthy  appearance. 

5.  Alternating  calculi,  consisting  of  alternate  layers  of  two  or 
more  primary  deposits. 

Symptoms. — In  the  absence  of  renal  colic  there  are  usually 
no  symptoms  to  attract  the  attention.  Renal  colic  is  mani- 
fested chiefly  by  agonizing  pain  in  the  back,  principally  in  the 
dorso-lumbar  region,  which  radiates  along  the  ureters  and  is 
worse  on  motion,  attended  by  retraction  of  the  testicle  on  the 
corresponding  side,  irritability  of  the  bladder,  pallor  of  the  face, 
pinched  features,  nausea,  vomiting,  lowering  of  surface  tem- 
perature, faintness,  and  rarely  unconsciousness.  The  paroxysm 
terminates  suddenly  after  some  minutes  or  a  few  hours,  the 
stone  escaping  into  the  bladder.  If  the  stone  is  not  passed  the 
attack  may  subside  to  recur  within  a  short  period.  The  urine 
is  more  or  less  suppressed,  usually  escaping  in  drops  and 
stained  with  blood.  If  the  condition  is  bilateral  and  both 
ureters  are  obstructed,  uremic  symptoms  occur.  This  is  rare. 
Obstruction  of  the  ureter  by  a  calculus,  if  unrelieved,  may 
terminate  in  pyelitis,  hydronephrosis,  or  pyonephrosis.  Sup- 
puration is  indicated  by  chills,  irregular  fever,  sweats,  .and 
leukocytosis. 

During  the  interval  between  the  attacks  there  is  more  or  less 
pain  and  tenderness  over  the  region  of  the  kidneys  and  the  urine 
is  stained  with  blood.  Its  specific  gravity  is  high,  and  albu- 
min and.  long,  narrow,  hyaline  casts  are  present.  Epithelium 
from  the  pelvis  of  the  kidney,  pus,  and  crystals  indicating  the 
character  of  the  calculus  may  also  be  found. 

Diagnosis. — The  distinctive  features  of  this  affection  are  pain 
and  tenderness  in  the  back,  persistent  hematuria,  albuminuria, 
scanty  urine  of  high  specific  gravity,  containing  hyaline  casts, 
24 


370  NEPHRO-LITHIASIS. 

pus,   and  crystals,   and  the  characteristic  paroxysms  of  renal 
colic.     The  x-rsiy  may  be  employed  to  confirm  the  diagnosis. 

In  biliary  colic,  jaundice  is  almost  aways  present,  the  stools 
are  grayish-white  in  color,  the  pain  is  nearer  the  median  line 
and  radiates  rather  to  the  upper   abdomen  and  right  shoulder, . 
and  the  urine  is  bile-stained. 

In  stone  in  the  bladder,  the  pain  radiates  toward  both  sides, 
is  worse  after  micturition,  and  the  stone  may  be  felt  by  a  sound. 

Prognosis. — The  outlook  is  guardedly  favorable  in  the  absence 
of  complications.  Impaction  may  produce  extensive  disorgan- 
ization of  the  kidneys,  or  its  passage  along  the  ureter  may 
prove  fatal.  Recurrences  are  common.  The  condition  known 
as  gravel  is  the  least  dangerous.  If  the  stone  is  large  or  there 
are  more  than  one,  the  prognosis  becomes  correspondingly 
more  serious. 

Treatment. — During  the  attack  a  hot  bath  should  be  ordered 
and  a  hypodermic  injection  of  morphin  and  atropin,  or  a  sup- 
pository of  extract  of  opium,  gr.  i  (0.065  g^i^-).  ^nd  alcoholic  ex- 
tract of  belladonna,  gr.  ss  (0.032  gm.),  should  be  administered. 
Hot  poultices  and  hot  fomentations  should  be  applied  to  the 
lumbar  region,  and  diluent  drinks  freely  consumed.  Chloro- 
form may  be  necessary  to  relieve  the  pain  in  some  cases.  The 
coal-tar  products  are  of  value  at  times.  During  mild  attacks 
of  gravel,  solution  of  potassium  citrate,  fSss  (15  c.c),  alone  or 
combined  with  camphorated  tincture  of  opium,  fSss  (2  c.c), 
is  of  value.  Hematuria  may  be  relieved  by  alum,  gr.  xx 
(1.3  gm.),  or: 

I^.     Fluidextracti  ergotae, 

Tinct.  krameriae aa  f  Sii  aa  60.  c.c. 

M.  S. — One  teaspoonful  every  two  hours. 

When  the  calculi  are  large,  numerous,  and  impacted,  or 
threaten  life,  a  surgical  operation  should  be  performed  for 
their  removal. 

During  the  interval  efforts  should  be  made  to  prevent  the 
formation  of  the  calculi.  There  are  no  remedies  that  will 
dissolve  fully  formed  calculi,  but  there  are  many  methods  by 


HYDRONEPHROSIS.  371 

which  the  various  crystals  in  the  blood  and  urine  may  be  kept 
in  solution  and  thus  prevent  the  formation  of  concretions.  If 
repeated  examinations  of  the  urine  show  a  tendency  toward 
the  uric  acid  diathesis,  the  alkalies,  such  as  Buffalo  Lithia 
Springs,  Rockbridge  Alum  Springs,  Saratoga,  Vichy,  Bedford, 
Poland,  and  similar  waters,  potassium  tartraborate  fcream  of 
tartar,  4  parts;  boric  acid,  i  part;  water,  10  parts;  dose,  gr.xx 
three  times  daily  diluted),  lithium  citrate,  gr.  v  to  x  (0.3  to  0.6 
gm.),  or  the  following  should  be  administered: 

I^.      Magnesii  carbonat 5j  4.  gm. 

Acid,  citrici oij  8  .  gm. 

Sodii  borat oij  8  .  gm. 

Aquae  bullientis 5viii  240.  c.c. 

M.  S. — Tablespoonful  three  times  daily,  diluted. 

The  diet  in  these  cases  should  consist  largely  of  milk  and  vege- 
tables, using  only  a  very  small  quantity  of  meat  and  other 
nitrogenous  foods. 

If  there  is  a  tendency  toward  the  deposition  of  phosphates 
with  the  formation  of  calculi,  a  diet  of  meat  and  nitrogenous 
substances,  acidulated  drinks,  distilled  water,  benzoic  acid, 
and  boric  acid,  are  indicated. 

Either  form  of  treatment  will  be  of  equal  value  if  there  is  any 
tendency  toward  concretion  of  the  oxalates.  Piperazin,  gr.  v 
(0.32  gm.),  three  times  daily,  has  been  employed  with  success 
in  renal  calculi. 


HYDRONEPHROSIS. 

Definition. — A  cystic  condition  of  the  kidney,  due  to  reten- 
tion of  secretion.  It  may  be  due  to  impaction  of  a  stone  in  the 
ureter,  stenosis  or  congenital  stricture  of  the  ureter,  or  some 
morbid  growth.  The  affection  begins  with  obstruction  of  the 
ureter,  and  is  followed  by  dilatation  of  the  pelvis  of  the  kidney. 
As  the  fluid  accumulates  it  presses  on  the  parenchyma  and 
induces  gradual  wasting  of  that  structure. 


372  TUBERCULOSIS    OF    THE    KIDNEY. 

Symptoms. — When  slight,  there  are  no  distinctive  manifesta- 
tions, but  when  the  amount  of  fluid  is  large,  there  appears  in 
the  lumbar  region  a  soft,  fluctuating,  painless  tumor,  over 
which  dullness  may  be  obtained  by  percussion.  A  clear  fluid, 
containing  urea  and  uric  acid,  will  be  withdrawn  on  aspiration. 
The  condition  may  be  intermittent  or  constant,  according  to 
whether  the  obstruction  is  or  is  not  relieved. 

Diagnosis. — The  history,  gradual  onset,  location  of  the  tumor, 
the  relation  of  its  size  to  the  urinary  excretion,  and  the  char- 
acter of  the  aspirated  fluid  will  aid  in  making  a  diagnosis,  but 
often  an  exploratory  incision  is  necessary. 

Prognosis. — The  affection  is  serious,  in  that  if  unrelieved  it 
tends  toward  disintegration  of  the  kidney  substance,  pyone- 
phrosis, rupture,  and  ultimately  death. 

Treatment. — The  treatment  is  entirely  surgical  and  includes 
aspiration,  nephrotomy,  and  nephrectomy. 

TUBERCULOSIS  OF  THE  KIDNEY. 

Tuberculosis  of  the  kidney  is  seldom  a  primary  affection,  and 
is  usually  a  part  of  a  tuberculous  infection  involving  the  entire 
urinary  tract.  It  is  most  common  in  young  adult  males,  and 
its  etiology  is  that  of  tuberculosis  in  other  regions.  As  else- 
where, its  lesions  may  be  miliary  tubercles  or  caseous  nodules. 
The  symptoms  resemble  pyelitis  from  other  causes,  and  a  dis- 
tinction often  can  only  be  made  by  the  detection  of  tubercle 
bacilli  in  the  urine.  (See  page  350.)  The  affection  is  very 
grave,  and  there  is  no  satisfactory  medical  treatment.  A 
surgical  operation  offers  the  only  hope  of  relief.  Untreated 
cases  live  from  a  few  months  to  two  or  three  years. 

PERINEPHRITIC  ABSCESS  OR  PARANEPHRITIS. 

Inflammation  of  the  capsule  and  the  connective  tissue  sur- 
rounding the  kidney  terminating  in  suppuration  and  abscess 
formation.  It  may  arise  from  traumatism,  or  it  may  be  due  to 
extension  by  perforation  of  a  renal  or  other  abdominal  abscess. 
It  is  attended  by  localized  pain,  tenderness,  and  edema;  and 


ACUTE    UREMIA.  373 

the  patient  flexes  the  corresponding  thigh  when  sitting  or  lying 
to  afford  more  comfort.  Chill,  fever,  and  sweats  are  present. 
The  condition  is  surgical  in  character,  but  should  always  be 
considered  as  a  possibility  in  medical  renal  affections  attended 
by  hectic  symptoms. 

ACUTE  UREMIA. 

Synonyms. — Uremic  poisoning;  uremic  intoxication;  uremic 
coma;  uremic  convulsions. 

Definition. — A  group  of  nervous  phenomena,  which  may  de- 
velop during  the  course  of  acute  or  chronic  Bright' s  disease, 
and  other  maladies,  the  result  of  the  retention  or  accumulation 
in  the  blood  of  excrementitious  material,  part  of  which  is 
supposed  to  be  urea. 

Causes. — It  is  an  intoxication,  but  the  nature  of  the  toxic 
substance  is  not  known.  Several  theories  are  held,  and  the 
following  may  still  be  viewed  as  probable  factors: 

Among  the  theories  that  have  been  put  forward,  are  the  fol- 
lowing: (i)  that  uremia  is  due  to  retention  in  the  blood  of 
excess  of  urea;  (2)  that  in  the  blood  urea  is  decomposed  into 
carbonate  of  ammonium,  and  that  it  is  this  latter  which 
causes  the  symptoms ;  (3)  that  it  is  not  only  the  retention  of  urea, 
but  the  retention  of  urea,  uric  acid,  alloxur  bases,  and  the  total 
excreta;  (4)  that  the  symptoms  are  due  partly  to  the  salts  of 
potassium,  and  partly  to  intermediate  products  of  proteid  waste; 
(5)  that  there  is  some  abnormal  body  present  in  the  urine,  due 
to  disease,  and  possibly  owing  to  the  failure  of  some  internal 
secretion.  Probably  no  simple  theory  will  explain  all  cases. 
Suppression  of  urine,  from  acute  or  chronic  Bright's  disease, 
probably  more  frequent  in  chronic  parenchymatous  nephritis; 
cystic,  tubercular,  or  cancerous  kidney;  the  puerperal  state; 
operations  on  the  uterus,  bladder,  urethra,  or  rectum. 

Symptoms. — Uremic  intoxication  is  the  result  of  the  failure 
of  the  kidneys  to  perform  their  normal  function  of  eliminating 
some  or  all  of  the  poisonous  elements  of  the  urine. 

The  toxemia  may  develop  suddenly,  by  a  convulsive  seizure 


374  ACUTE    UREMIA. 

followed  by  coma,  or  slowly  and  gradually.  Usually  the  at- 
tack is  preceded  by  a  decrease  in  the  urinary  secretion  and 
slight  or  marked  edema  in  various  parts  of  the  body;  although 
it  must  be  borne  in  mind  that  in  rare  instances,  during,  or 
immediately  prior  to,  the  appearance  of  the  uremic  phenomena, 
the  normal  urinary  flow  has  been  largely  exceeded. 

The  acute  outbreak  may  manifest  itself  in  a  variety  of  ways. 

Gastrointestinal  Variety. — The  patient  suddenly  experiences 
attacks  of  vertigo,  pallor  of  face,  nausea  and  vomiting,  with 
fever,  the  temperature  varying  between  ioo°  and  103°  F.,  pulse 
tense  and  rapid,  respiration  hurried,  and  the  urine  scanty  with 
low  specific  gravity;  unless  symptoms  are  promptly  relieved, 
convulsions  or  drowsiness  may  occur,  followed  by  coma  and 
death.  Rarely  an  acute  maniacal  outbreak  follows  the  gastro- 
intestinal symptoms. 

Convulsive  Variety. — Without  any  appreciable  prodromes, 
epileptiform  convulsions  may  occur,  with  or  without  loss  of 
consciousness.  The  convulsions  may  consist  of  a  single  parox- 
ysm, or  a  succession  of  fits  may  follow  one  another  at  intervals 
of  a  few  minutes  or  several  hours,  the  patient  being  in  a  condition 
of  more  or  less  profound  insensibility  during  the  intervals. 
The  fits  closely  simulate  true  epilepsy.  In  this  variety  the 
temperature  is  high,  from  103°  to  106°  F.  or  more,  the  pulse 
rapid,  with  or  without  tension,  the  respirations  quickened. 
Coma  followed  by  death  is  a  very  common  ending  of  this  variety 
of  uremia ;  or  after  a  profound  sleep  of  hours  the  patient  grad- 
ually recovers  his  usual  health.  Alcoholic  excesses  are  respon- 
sible for  many  of  these  attacks. 

Cerebral  Variety,  or  Uremic  Coma. — Develops  gradually,  with 
an  increasing  drowsiness,  associated  with  headache  and  irrita- 
bility of  temper  (mild  mania).  Nausea,  vomiting,  and  rise  of 
temperature,  often  reaching  105°,  rarely  107°  F.,  with  rapid, 
full  pulse  may  be  present,  or  the  patient  may  fall  suddenly  into 
a  condition  of  profound  coma,  the  symptoms  closely  resembling 
an  apoplectic  stroke,  excepting  the  high  temperature.  Tem- 
porary blindness  and  transient  paralysis  are  not  uncommon. 
Uremic  coma  is  always  accompanied  with  rise  of  temperature 


ACUTE    UREMIA.  375 

and  stertor.  "The  stertor  is  peculiar;  it  is  not  the  'snoring' 
of  apoplexy,  but  a  sharp,  hissing  sound  produced  by  the  rush 
of  expired  air  against  the  teeth  or  hard  palate"  (Loomis).  The 
respirations  are  accelerated,  the  pulse  rapid  but  minus  tension. 
This  variety  may  suddenly  terminate  fatally  with  a  convulsion, 
or  a  deepening  coma  with  prostration  and  cold,  wet  skin,  with 
edema  of  the  lungs,  or,  rarely,  in  gradual  recovery. 

Diagnosis. — Uremia  resembles  a  number  of  conditions  in 
which  convulsions  and  coma  are  prominent  symptoms.  A 
specimen  of  urine  should  always  be  obtained  and  tested  for 
albumin.  The  quantity  is  scant  and  the  percentage  of  urea  is 
decreased.  Other  signs  of  kidney  •  disease  are  present.  The 
breath  has  a  urinous  odor;  the  arterial  tension  is  often  high; 
the  second  aortic  sound  is  accentuated;  the  pupils  are  small  and 
equal,  and  in  acute  outbreaks  there  is  a  rise  of  temperature 
due  to  irritation  of  the  heat  centers. 

Uremic  coma  may  closely  simulate  coma  from  other  causes. 
Cerebral  apoplexy  may  be  distinguished  by  its  history,  the  age  at 
which  it  occurs,  generalized  arterial  sclerosis,  the  slow,  noisy, 
irregular  respiration,  the  pulse  is  slow  and  full,  the  pupils  are 
uninfluenced  by  light,  conjugate  deviation  of  the  eyes,  the  face 
is  flushed,  subnormal  temperature  at  first,  with  a  subsequent  rise 
above  normal,  permanent  one-sided  paralysis,  and  an  absence  of 
the  urinary  symptoms  common  to  uremia. 

Epilepsy  is  attended  by  coma  of  short  duration.  The  attack 
is  preceded  by  a  sharp  cry  and  extreme  pallor  of  the  face,  the 
countenance  being  dusky  in  uremia.  The  history,  age  of  the 
patient,  and  the  presence  or  absence  of  urinary  symptoms 
should  be  considered  in  making  the  diagnosis. 

Sunstroke  may  be  recognized  by  the  accompanying  circum- 
stances, the  history,  the  extremely  high  temperature,  and  the 
absence  of  albuminuria,  and  other  characteristic  urinary  symp- 
toms of  uremia. 

Opium,  poisoning  is  manifested  by  contraction  of  the  pupils, 
slow  respiration,  slow  full  pulse,  and  the  odor  of  laudanum  at 
times.     An  examination  of  the  urine  will  exclude  uremia. 

Alcoholism,  may  be  differentiated  by  its  history,  odor  of  the 


376  ACUTE    UREMIA. 

breath,  incomplete  loss  of  consciousness,  and  the  absence  of 
urinary  symptoms,  dropsy,  etc.  Pressure  applied  over  the 
supraorbital  notches  with  increasing  force  will  serve  to  produce 
consciousness  in  alcoholism. 

Prognosis. — The  condition  is  very  serious.  The  attack  may 
end  in  recovery,  but  recurrences  are  common  and  the  affection 
ultimately  terminates  in  death. 

Treatment. — During  an  attack,  while  the  patient  is  uncon- 
scious, elimination  should  be  procured  by  the  administration  of 
one  or  two  drops  of  croton  oil,  diluted  by  glycerin  or  sweet  oil,  or 
gr.  1/4  (0.0165  gm.)  of  elaterium  in  solution  by  the  mouth, 
the  following  enema  may  be  used: 

I^.     Magnesii  sulph §ij  60.  gm. 

Glycerini §j  30.  c.c. 

Aquae  bul 5iv  120.  c.c. 

M.  S. — As  enema. 

Free  sweating  should  be  encouraged  by  the  use  of  the  hot  pack, 
vapor  bath,  or  hot-air  bath,  together  with  the  hypodermic 
injection  of  pilocarpin  hydrochlorid,  gr.  1/4  (0.016  gm.),  or 
the  rectal  injection  of  an  infusion  of  jaborandi  leaves  (jaborandi 
oi,  water  5iv).  In  robust  individuals,  venesection,  or  cupping 
may  be  performed.  In  feeble  patients,  during  diaphoresis, 
the  tendency  toward  edema  of  the  lungs  should  be  combated 
by  the  hypodermic  injection  of  atropin  sulphate,  gr.  1/60 
(0.00 1  gm.),  and  strychnin  sulphate,  gr.  1/32  (0.002  gm.). 
The  convulsions  are  relieved  by  inhalations  of  chloroform, 
chloral  by  the  rectum,  morphin  hypodermically,  and  vene- 
section. When  the  flow  from  a  vein  is  only  a  few  drops,  it 
may  be  increased  by  the  hypodermic  injection  of  amyl  nitrite, 
TTLv  (0.3  c.c),  with  aromatic  spirits  of  ammonia,  nixv  (i  c.c). 

Diviresis  should  be  promoted  by  dry  or  wet  cupping,  poultices 
over  the  loins,  hot  compresses  of  infusion  of  digitalis  over  the 
abdomen,  pilocarpus  rubbed  over  the  kidneys,  and  the  use  of 
normal  salt  solution  subcutaneously  or  by  the  bowel.  Drugs 
such  as  infusion  of  digitalis,  citrated  caffein,  spartein  sulphate, 
nitroglycerin,  and  diuretin  may  be  given  hypodermically,  or 
by  the  mouth  if  the  patient  is  able  to  swallow. 


MOVABLE    KIDNEY.  377 

During  the  intervals  or  the  prodromal  period  these  measures 
should  also  be  employed  together  with  other  drugs  by  the  mouth. 
The  diet  should  be  milk  in  large  quantities.  Sodium  benzoate, 
oi  to  ii  (4  to  8  gm.),  in  twenty-four  hours,  may  be  administered 
as  it  is  believed  to  materially  influence  the  condition. 

When  the  gastrointestinal  variety  is  present  the  patient 
should  be  placed  in  bed  and  the  magnesium  sulphate  enema 
and  citrated  caffein,  gr.  iii  (0.2  gm.),  every  three  hours,  should 
be  administered.  When  the  secretions  have  started  one  of  the 
following  powders  should  be  given  every  two  hours  for  twenty- 
four  hours  followed  by  Hunyadi  Janos  water: 

J^.      Hydrargyri  chlor.  mitis .    gr.  1/4  to  1/2     .016  to  .032  gm. 

Sodii  bicarb gr-  ij  .130  gm. 

Pulv.  ipecacuanhae -.    gr.  1/6  .011  gm. 

M.      Disp.  in  chart.  No.  i. 
S. — Use  as  directed.. 

The  following  formulas  will  be  found  of  great  value,  in  bringing 
about  diaphoresis: 

I^.      Sparteinas  sulphat gr-  iv  .265  gm. 

Pilocarpinae  hydrochlor. .    gr.  j  "  .065  gm. 

Infus.  digital f  5ij  60.  c.c. 

M.  S. — Teaspoonful  every  half  hour  or  hour  until  desired 
effect  is  obtained. 

I^.      Digitalinse  cryst gr.  1/64  .001  gm. 

Pilocarpinae     hydrochlor   gr.    1/4  .016  gm.  ■ 

Sparteinae  sulph gr.  1/2  .032  gm. 

Aquae  destil tt^xv  i  .  c.c. 

M.   S. — For  hypodermic  use;  to  be  repeated  as  necessary. 

I^.     Pilocarpine  nitrat gr-  ij  .13  gni. 

Petrolat f  §  j  32  .       gm. 

M.  S. — Apply  locally  over  the  kidneys  twice  daily. 

MOVABLE  KIDNEY. 

Synonyms.  —  Floating  kidney;  wandering  kidney;  nephro- 
ptosis. 

Definition. — A  condition  of  the  kidney,  either  congenital  or 
acquired,  in  which  the  tissues  around  and  about  the  organ  are 


378  MOVABLE    KIDNEY. 

SO  lax  and  the  renal  vessels  so  elongated  as  to  permit  the  kidney 
to  be  moved  in  certain  directions,  causing  a  movable  tumor  in 
the  abdomen. 

Causes.^ — The  kidney  is  normally  held  in  position  by  the 
layer  of  peritoneum  which  is  attached  to  the  anterior  surface 
of  its  adipose  capsule.  In  movable  kidney  the  adipose  tissue,  in 
which  the  normal  kidney  is  imbedded,  disappears.  The  renal 
vessels  are  in  many  cases  abnormally  long.  The  condition  may 
be  congenital  or  acquired  and  occurs  with  greatest  frequency  in 
women.  Relaxation  of  the  abdominal  walls  from  pregnancy  or 
other  conditions,  the  wearing  of  tight  corsets  or  girdles  about 
the  waist,  violence,  increased  weight  of  the  kidney,  pressure  of 
adjacent  tumors,  traction  of  hernia,  and  rapid  emaciation  are 
important  etiologic  factors. 

Symptoms.  —  Subjective  symptoms  maybe  absent  entirely. 
In  many  cases,  the  patient  experiences  a  heavy,  dragging  pain  in 
the  abdomen,  aggravated  by  standing  or  walking.  Gastroin- 
testinal symptoms,  mental  anxiety,  and  hysterical  manifesta- 
tions often  accompany  the  condition.  Various  reflex  disturb- 
ances may  be  present,  such  as  palpitation  of  the  heart,  neu- 
ralgic pains,  cardialgia,  irritability  of  the  bladder,  etc.  Tor- 
sion of  the  ureter  and  renal  vessels  may  occur  at  any  time  and 
is  manifested  by  paroxysms  of  intense  pain  with  symptoms  of 
collapse.  The  kidney  at  times  swells  without  apparent  cause 
and  becomes  sensitive  to  the  touch.  Its  tendency  to  change 
its  position  is  its  characteristic  feature,  and  the  displaced  organ 
may  be  found  anywhere  in  the  abdomen.  Gastroptosis  or  en- 
teroptosis  may  accompany  it. 

Diagnosis. — Physical  examination  is  necessary  in  all  cases. 
The  detection  of  a  freely  movable  reniform  tumor  of  fixed  size 
and  the  absence  of  the  kidney  from  its  normal  situation  are 
the  distinctive  features.  The  right  kidney  is  most  often  af- 
fected; pulsation  of  the  renal  artery  may  occasionally  be  felt. 

Prognosis. — The  affection  is  extremely  chronic,  but  rarely  if 
ever  terminates  fatally  in  the  absence  of  complications. 

Treatment. — Measures  directed  toward  improvement  of  the 
general  health  are  advised.    In  many  cases  the  symptoms  are  en- 


CYSTITIS.  379 

tirely  relieved  by  lying  on  the  back  or  by  wearing  a  suitable 
abdominal  supporter  to  retain  the  kidney  in  its  proper  situation. 
When  the  paroxysms  occur,  rest  in  bed,  hot  applications  over 
the  lumbar  regions,  and  opiates  will  be  necessary.  If  these  recur 
frequently,  some  form  of  surgical  treatment  such  as  nephror- 
rhaphy,  fixing  the  organ  by  sutures,  or  extirpation  will  be 
required. 

CYSTITIS. 

Synonym. — Catarrh  of  the  bladder. 

Definition. — An  infectious  inflammation  of  the  vesical  mu- 
cous membrane,  acute  or  chronic  in  course,  generally  caused  by 
pathogenic  bacteria,  and  characterized  by  rigors,  moderate 
fever,  hypogastric  pain,  frequent  but  scanty  urination,  pus 
in  the  urine  (pyuria),  and  severe  vesical  tenesmus. 

Causes. — Acute  cystitis  may  be  due  to  long-continued  re- 
tention of  urine,  foreign  bodies  in  the  bladder,  pyelitis,  urethritis 
traumatism,  or  the  infectious  fevers,  especially  diphtheria. 
Among  the  bacteria  that  may  be  found  are  the  Bacillus 
coli  communis,  gonococcus,  Staphylococcus  pyogenes,  and  Bac- 
illus tuberculosis.  These  are  probably  the  real  causes,  the 
other  conditions  simply  predisposing.  Chronic  cystitis  may 
follow  the  acute  variety  or  may  arise  from  chronic  Bright' s 
disease,  gout,  calculi,  or  retention  of  urine  such  as  follows 
enlarged  prostate  and  urethral  stricture. 

Pathologic  Anatomy. — Acute  catarrhal  cystitis  begins  with 
hyperemia  of  the  mucuous  membrane  which  is  manifested  by 
redness,  swelling,  and  edema.  If  the  congestion  is  intense,  the 
smaller  capillaries  may  rupture  causing  extravasation  of  blood. 
Following  the  hyperemia,  increased  secretion  of  the  small  glands 
at  the  base  of  the  bladder  and  an  increased  growth  and  con- 
sequent desquamation  of  the  vesical  epithelium  occur.  If  the 
inflammation  is  intense  it  may  terminate  in  suppuration,  ulcer- 
ation, or  in  the  formation  of  a  false  membrane. 

In  chronic  cystitis  "the  mucous  membrane  is  thick,  blue- 
gray  in  color,  and  very  tough.     Muco-pus  and  viscid  mucus  are 


380  CYSTITIS. 

formed  in  large  quantities  upon  its  surface.  The  muscular  wall 
of  the  bladder  may  sometimes  be  half  an  inch  thick,  and  the 
fasciculi  give  a  ribbed  appearance  to  the  internal  surface, 
called  the  *  columnar  bladder. '  The  hypertrophy  of  chronic 
cystitis  may  be  eccentric  or  concentric.  In  some  cases  diver- 
ticuli  are  formed,  in  whose  walls  are  dilated  and  tortuous 
veins.  In  nearly  all  cases  bacteria  are  found  in  abundance" 
(Loomis). 

Symptoms. — Acute  cystitis  is  characterized  by  an  abrupt  onset 
with  rigors,  slight  fever,  loss  of  appetite,  sleeplessness,  and  a  feel- 
ing of  depression.  -  Micturition  is  frequent  but  the  urine  is  only 
voided  drop  by  drop  and  its  passage  is  followed  by  distressing 
vesical  tenesmus.  Dull  pain  over  the  bladder  and  in  the  iliac  re- 
gions, and  burning  along  the  urethra  are  present.  The  urine  is 
cloudy,  of  an  alkaline  reaction,  and  at  times  fetid.  Microscopic 
examination  shows  epithelium,  pus,  red  blood  corpuscles,  and 
various  forms  of  bacteria. 

Chronic  cystitis  is  attended  by  an  insidious  onset  and  is  mani- 
fested by  dull  pain  and  frequent,  scanty  urination.  If  there  is 
ulceration  of  the  vesical  mucous  membrane,  severe  localized 
pain,  hematuria,  and  emaciation  will  also  be  present.  In  all 
cases  there  are  in  addition  the  symptoms  of  some  obstructive 
condition  such  as  stricture,  calculus,  or  enlarged  prostate  together 
with  debility  and  mental  depression.  The  urine  is  alkaline  and 
contains  large  amounts  of  muco-pus  or  pus.  On  standing  it  de- 
posits a  thick,  glairy,  viscid  sediment  in  which  triple  phosphates 
and  large  pus  corpuscles  may  be  detected  by  the  microscope. 
Although  the  quantity  of  urine  voided  by  the  patient  is  small, 
the  use  of  the  catheter  after  micturition  will  in  most  cases 
serve  to  withdraw  several  ounces  of  fetid,  cloudy,  alkaline  urine. 

Diagnosis. — The  reaction  and  characteristics  of  the  urine, 
together  with  the  history  will  serve  to  distinguish  cystitis  from 
pyelitis,  interstital  nephritis,  and  similar  conditions. 

Prognosis. — The  outlook  in  acute  cystitis  is,  as  a  rule,  favor- 
able, but  is  controlled  to  a  great  extent  by  the  character  of 
the  cause.  The  chronic  variety  tends  to  persist  indefinitely  and 
is  incurable  after  hypertrophy  of  the  bladder  has  occurred. 


CYSTITIS.  381 

Treatment. — In  the  acute  variety,  the  patient  should  be  placed 
in  bed,  and  a  liquid  diet,  preferably  milk,  should  be  ordered, 
care  being  taken  to  eliminate  all  highly  seasoned  articles.  Warm 
applications  should  be  made  over  the  bladder  and  occasionally 
cupping  or  leeching  may  be  required.  The  urine  should  be  well 
diluted  by  large  draughts  of  pure  water  or  the  alkaline  mineral 
waters  such  as  Farmville  lithia,  Buffalo  lithia,  Rockbridge  alum, 
or  Vichy  waters.  Alkalinity  of  the  urine  from  any  cause  is 
relieved  by  the  administration  of  ammonium  benzoate,  gr. 
XX  (1.3  gm.),  in  water  or  the  solution  of  potassium  citrate,  oi 
(3.7  c.c).  For  the  pain  and  tenesmus,  a  suppository  of  extract 
of  opium  and  extract  of  belladonna  may  be  necessary  in  addition 
to  the  hot  applications  and  hot  enemas.  Fluidextract  of  cannabis 
indica,  n^xv  to  xxx  (i  to  2  c.c),  every  three  hours,  often 
relieves  the  tenesmus.  A  free  movement  of  the  bowels 
obtained  by  the  administration  of  a  saline  cathartic  is  always 
of  value  in  lessening  the  inflammation  and  its  attendant 
symptoms.  The  following  formulas  are  also  of  decided  value 
in  this  condition: 

I^.      Acidi  benzoici 

Sodii  borat aa    5ij  aa  8  .  gm. 

Infusi  buchu,  vel. 

Infusi  uvae  ursi Bvj  180.  c.c. 

M.  S.— Tablespoonful  every  two  hours,  well  diluted. 

I^.      Tinct.  hyoscyami 5vj  24.     c.c. 

Tinct.  opii  camph 5vj  24.     c.c. 

Potassii  bromidi 

Sodii  bicarb aa     5ijss  aa  10.    gm. 

Liq.  potassii  citrat.  q.s. ad    oviij         q.s.  240.     c.c. 
M.  S. — One  teaspoonful  every  two  hours,  well  diluted. 

A  valuable  prescription  is : 

I^.      Fluidextract  pichi f§j  30.  c.c. 

Potassii  nitrat 5  j  _   4  .  gm. 

Elix.  simplicis f  oiij  90  .  c.c. 

M.  S. — One  teaspoonful  every  two  hours,  well  diluted. 


382  EXAMINATION    OF    THE    BLOOD. 

Chronic  cystitis  requires  also  a  mild  unirritating  diet  and  the 
free  use  of  the  alkaline  mineral  waters.  The  bladder  should  be 
emptied  several  times  daily  to  prevent  accumulation  and  conse- 
quent decomposition  of  the  urine,  the  underlying  cause  mean- 
while receiving  appropriate  treatment.  Eucalyptol,  gtt.  x  to  xv 
(0.6  to  I  C.C.),  every  four  hours  diluted,  fiuidextract  of  grindelia 
nxxx  to  f  3i  (1.3  t0  4C.c.),  three  times  daily,  orsantal  oil,  gtt.  vtox 
(0.3  to  0.6  cc),  in  emulsion  or  capsule  after  meals,  may  be  ad- 
ministered internally.  Urotropin,  gr.  v  to  viiss  (0.3  to  0.5  gm.), 
boric  acid,  gr.  v  to  x  (0.32  to  0.65  gm.),  benzoic  acid,  gr.  v  to  xx 
(0.32  to  1.30  gm.),  naphthalin,  gr.  ii  (0.13  gm.),  salol,  gr.  x 
(0.65  gm.),  or  resorcin,  gr.  v  (0.32  gm.)  may  also  be  employed. 
Irrigation  of  the  bladder  under  aseptic  precautions  is  a  very 
important  feature  of  the  treatment.  Tepid  water  should  be 
used  at  first  after  which  medicated  solutions  may  be  employed. 
Not  more  than  from  2  to  4  ounces  of  fluid  should  be  injected 
at  first  until  the  capacity  of  the  bladder  has  been  ascertained. 
Daily  injections  are  usually  sufficient.  Sodium  salicylate,  5i 
(4  gm.),  to  the  pint  (1/2  liter),  boric  acid,  5i  (4  gm.),  to  the 
pint  (1/2  liter),  silver  nitrate,  gr.  1/4  (0.016  gm.)  to  the  ounce 
(30  cc),  or  the  following  are  the  fluids  most  commonly  used 
for  this  purpose : 

I^.      Sodii  borat 5 j  30 .  gm. 

Glycerini f  5ij  60 .  cc. 

Aquae f  Bij  60.  cc. 

M.  S. — Add  one  to  two  tablespoonfuls  to  warm  water  and 
use  as  directed. 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

EXAMINATION  OF  THE  BLOOD. 

Normal  blood  consists  of  plasma,  corpuscles,  and  plaques. 
The  corpuscles  are  red  and  white.  The  ordinary  red  blood  cell 
is  1/3200  of  an  inch  in  diameter  and  varies  in  number  from 
4,500,000   to    5,000,000   to   the   cubic   millimeter.      It   contains 


EXAMINATION    OF    THE    BLOOD.  383 

hemoglobin,  the  oxygen  carrier  of  the  blood.  The  white  blood 
cells  measure  1/2500  of  an  inch  in  diameter  and  number  from 
7,000  to  10,000  to  the  cubic  millimeter.  The  blood  plaques 
number  about  200,000  to  the  cubic  millimeter. 

The  specific  gravity  of  normal  blood  varies  from  1,050  to  1,060. 
It  may  be  ascertained  by  the  preparation  of  a  number  of  solu- 
tions of  glycerin  and  water  of  varying  specific  gravities  from 
1,040  to  1,080.  A  drop  of  blood  is  placed  in  each  solution.  The 
solution  in  which  the  drop  of  blood  remains  stationary  is  of  the 
same  specific  gravity  as  the  blood  under  examination  Ham- 
merschlag  adds  a  drop  of  blood  to  a  mixture  of  chloroform  and 
benzol  and  then  increases  the  quantity  of  either  constituent 
until  the  drop  of  blood  neither  rises  nor  falls  but  becomes  station- 
ary. The  specific  gravity  of  the  mixture  is  then  taken  by  the 
ordinary  means.  Increased  specific  gravity  of  the  blood  is 
observed  in  infancy  and  in  acute  febrile  diseases  such  as  diph- 
theria, pneumonia,  pleurisy,  etc.  Decreased  specific  gravity 
is  common  in  healthy  women,  and  in  anemia,  chlorosis,  and 
leukemia. 

The  reaction  of  the  blood  is  normally  alkaline.  The  alka- 
linity is  diminished  in  pernicious  anemia,  simple  anemia, 
leukemia,  uremia,  diabetes,  jaundice,  chronic  rheumatism, 
gout,  carbon  dioxid,  and  phosphorous  poisoning,  febrile  affec- 
tions, and  cachectic  conditions.  It  is  said,  by  some  observers, 
to  be  increased  in  chlorosis. 

The  color  of  the  blood  may  vary  considerably.  To  the  un- 
aided eye  arterial  blood  appears  bright  red  while  venous  blood  is 
darker  in  color.  Deficient  oxidation  from  any  cause  gives  rise  to 
darkening  of  the  arterial  blood.  The  blood  is  pale  in  chlorosis, 
hydremia,  and  leukemia,  and  is  of  an  abnormally  bright  red  color 
in  poisoning  by  carbon  monoxid.  It  assumes  a  brownish  red  or 
chocolate  color  in  poisoning  by  hydrocyanic  acid,  nitrobenzol, 
anilin,  and  chlorate  of  potassium. 

Hemoglobin,  the  coloring  matter  of  the  blood,  may  be  ap- 
proximately estimated  by  means  of  Von  Fleischl's,  Dare's,  or 
Tallquist's  hemoglobinometer,  or  by  the  specific  gravity  method. 
Von  Fleischl's  method  requires  a  metal  stand  with  a  stage  per- 


384 


EXAMINATION    OF    THE   BLOOD. 


forated  by  a  central  circular  opening  beneath  which  is  placed  a 
plaster-of -Paris  reflector.  A  small  cell  having  a  glass  bottom 
and  divided  into  two  compartments  is  provided  to  fit  into  the 
circular  opening.  A  wedge-shaped  piece  of  glass,  colored  with 
Cassius'  gold-purple  which  increases  in  intensity  as  the  thick 
portion  is  reached,  is  mounted  in  a  frame  and  interposed  be- 
tween the  reflector  and  the  circular  opening.  A  graduated 
scale  is  provided  on  the  frame  which  may  be  moved  back  and 
forth  by  a  rack  and  pinion.  The  wedge  of  the  glass  is  so  sit- 
uated as  to  obstruct  only  one-half  of  the  area  of  the  circular  open- 
ing. In  using  the  apparatus 
each  compartment  of  the 
cylindric  cell  is  filled  with  dis- 
tilled water  and  the  wedge- 
shaped  glass  placed  at  zero  on 
the  scale.  A  drop  of  blood  is 
withdrawn  and  cariied  by 
means  of  a  special  capillary 
tube  to  the  compartment  op- 
posite the  unobstructed  open- 
ing. The  glass  is  then  slowly 
moved  along  until  the  colora- 

FiG.  4o.-VonFi^i^^hr7h^^iobinometer.    ^ion  of  both  compartmcnts  is 
{From  Greene's  Medical  Diagnosis.)   the  Same.    The  percentage  may 

then  be  read  from  the  scale.  In  the  average  person,  a 
registration  of  85  to  90  per  cent,  on  this  scale  may  be  con- 
sidered normal.  A  darkened  room,  using  a  candle  for  illumi- 
nation, is  necessary  for  the  best  results  by  this  method.  The 
specific  gravity  method  is  more  easily  performed.  Benzol  and 
chloroform  are  mixed  together  forming  a  solution  having  a 
specific  gravity  of  about  1,059.  ^  drop  of  blood  is  placed 
in  the  mixture.  Chloroform  is  added  if  it  sinks,  and  benzol 
if  it  rises  to  the  top,  until  the  drop  of  blood  is  stationary, 
showing  that  it  and  the  liquid  are  of  the  same  density.  The 
specific  gravity  is  then  taken  in  the  usual  way  and  the  percent- 
age of  hemoglobin  may  be  calculated  from  the  following  table  by 
Hammerschlag : 


EXAMINATION    OF    THE    BLOOD. 


385 


Specific  Gravity 
1033  — 1035 
1035— 1038 
1038 — 1040 
1040 — 1045 
1045 — 1048 
1048 — 1050 
1050— 1053 

1053  — 1055 

1055 — i°57 
1057 — 1060 


Hemoglobin. 
25 — 30  per  cent. 
30 — 35  percent. 
35 — 40  per  cent. 
40 — 45  per  cent. 
45 — 55  per  cent. 
55 — 65  per  cent. 
65 — 70  per  cent. 
70 — 75  per  cent. 
75 — 85  per  cent. 
85 — 95  per  cent. 


Heraoglobin  is  decreased  in  chlorosis  and  all  forms  of  anemia 
and  is  said  to  be  increased  in  pulmonary  stenosis. 

The  number  of  blood  cells  is  best  determined  by  means  of 
the  Thoma-Zeiss  hemocytometer.  This  apparatus  consists  of  a 
glass  slide  with  a  central  cell,  the 
depth  of  which  is  i/io  mm.  Micro- 
scopic lines  divide  the  floor  of  this 
cell  into  400  squares  each  having  a 
cubic  capacity  of  1/4000  mm.  The 
surface  of  each  square  is  1/400 
square  mm.  Double  lines  are  used 
to  riiark  off  groups  of  16  squares. 
Two  pipets  are  used  for  diluting  the 
blood,  the  one  graduated  to  100  is 
employed  for  the  red  cells  while  the 
one  with  the  smaller  scale  is  used  for 
the  white  cells.  Each  pipet  is  blown 
into  a  bulb  near  one  extremity  to 
permit  mixing  of  the  blood  with  the 
diluting  fluid.  The  diluting  fluids 
commonly  employed  are  normal  salt  solution,  a  2  1/2  per  cent,  of 
bichromate  of  potash  solution,  andToisson's  fluid  (methyl  violet,. 
0.025  gi^-J  sodium  chlorid,  i  gm. ;  sodium  sulphate,  8  gm. ; 
glycerin,  30  c.c;  distilled  water,  160  c.c).  A  1/2  per  cent  solu- 
tion of  acetic  acid  is  used  in  counting  the  white  cells.     The 

25 


Fig.  41. — Thoma-Zeiss  hemo- 
cytometer, showing  pipet,  count- 
ing chamber,  and  ruled  field. 
(From  Greene's  Medical  Diagnosis .) 


386  EXAMINATION  OF  THE  BLOOD. 

blood  is  diluted  in  the  proportion  of  i  to  100  or  i  to  200  in  the 
enumeration  of  the  red  blood  cells  and  in  the  proportion  of  i 
to  10  or  I  to  20  in  determining  the  number  of  white  blood  cells. 

In  the  practical  application  of  this  apparatus,  the  puncture  is 
made  in  the  skin  and  the  drop  of  blood  sucked  up  to  the  mark 
I  c.c.  on  the  pipet.  The  diluting  fluid  is  then  drawn  into  the 
tube  until  the  mark  loi  is  reached  (for  red  blood  cells).  The 
blood  and  diluting  fluid  are  then  carefully  mixed  and  after  the  first 
few  drops  from  the  pipet  have  been  rejected,  a  drop  of  the  mix- 
ture is  placed  in  the  cell  of  the  slide  and  covered  by  a  cover-glass. 
After  five  or  ten  minutes  the  slide  is  placed  under  a  microscope 
and  the  corpuscles  counted.  In  the  calculation,  the  number  of 
corpuscles  counted  in  all  the  squares  should  be  multiplied  by  4000 
and  the  product  by  the  dilution.  This  entire  product  should 
then  be  divided  by  the  number  of  squares  counted,  the  quotient 
being  the  number  of  corpuscles  in  i  cm.  of  blood. 

The  white  blood  cells  appear  in  several  forms,  each  of  which 
requires  special  study. 

The  small  lymphocyte  varies  from  5  to  10  microns  in  diameter 
being  nearly  the  same  size  as  the  red  blood  corpuscles.  It  is  sur- 
rounded by  a  thin,  scarcely  visible  ring  of  protoplasm.  The  nu- 
cleus is  round  and  large  and  appears  greenish  blue  when  stained 
by  the  acid  fuchsin  of  Ehrlich's  triple  stain.  In  health  these 
cells  constitute  from  20  to  30  per  cent,  of  all  the  colorless  blood 
corpuscles. 

The  large  lymphocyte  is  a  large  mononuclear  cell  possessing  the 
same  characteristics  as  the  preceding  with  the  exceptions  that 
the  nucleus  is  round  or  oval  and  stains  less  deeply,  and  the  non- 
granular protoplasm  is  relatively  larger  in  amount.  The  diam- 
eter of  this  cell  may  be  as  high  as  13  to  15  microns.  Transitional 
forms  between  the  small  and  the  large  lymphocyte  are  also  en- 
countered.  The  percentage  of  large  lymphocyte  varies  from  4  to  8 . 

The  transitional  forms  resemble  the  foregoing  except  that 
their  nuclei  are  indented,  or  horse-shoe  shaped  and  the  proto- 
plasm is  neutrophilic. 

Polynuclear  leukocytes  are  smaller  than  the  large  lymphocytes 
and  occur  in  three  forms.     The  polymorphonuclear  neutrophiles 


EXAMINATION    OF    THE    BLOOD.  387 

are  matured  leukocytes  and  constitute  from  62  to  70  percent,  of 
the  white  blood  cells.  The  nucleus  is  decidedly  irregular  and 
stains  a  greenish  blue  or  green  with  Ehrlich's  triple  stain.  The 
protoplasm  and  nucleus  contain  fine  granules  which  stain  only 
with  neutral  stains.  With  Ehrlich's  solution  they  appear  violet 
or  purple,  while  the  intervening  matrix  has  a  pinkish  color.  The 
eosinophiles  are  smaller  than  the  neutrophiles,  but  contain 
larger  granules  which  have  a  great  affinity  for  acid  stains  such 
as  eosin  and  the  acid  fuchsin  of  Ehrlich's  triple  stain.  Eosin 
stains  these  granules  a  brilliant  pink  while  the  acid  fuchsin  of 
Ehrlich's  stain  causes  them  to  assume  a  copper-red  color.  There 
may  be  more  than  one  nucleus  which  may  be  recognized  by  the 
blue  color  in  the  presence  of  either  of  the  already-mentioned 
stains.  Eosinophiles  may  be  considered  as  hypermature  leuk- 
oyctes  and  constitute  from  1/2  to  4  per  cent  of  the  white  blood 
cells. 

The  hasophiles  or  mast  cells  contain  granules  which  are  un- 
stained by  Ehrlich's  solution  but  which  stain  in  basic  solutions 
of  the  anilin  dyes  such  as  methylene-blue.  These  cells  constitute 
from  1/4  to  1/2  per  cent,  of  the  white  blood  cells.  Myelocytes 
are  large,  non-ameboid,  blood  cells  resembling  the  large  granular 
cells  of  the  bone  marrow.  The  nucleus  is  single  and  stains  pale 
with  the  Ehrlich  stain.  The  protoplasmic  granules  are  usually 
neutrophilic. 

The  red  blood  cells  in  certain  abnormal  conditions  undergo 
changes  in  size,  shape,  and  characteristics.  Nucleated  red  blood 
corpuscles  are  occasionally  encountered  and  may  appear  as 
noi'moblasts ,  megaloblasts,  and  niicroblasts.  Normoblasts  are 
about  the  size  of  the  ordinary  red  cells  which  they  represent  in 
the  immature  state.  '  With  the  Ehrlich- Biondi  stain  the  nu- 
cleus assumes  a  very  deep  blue  color.  Megaloblasts  are  large 
and  irregular  cells  possessing  large  nuclei  which  stain  pale  green 
with  the  Ehrlich- Biondi  solution.  Microblasts  appear  as  very 
small  nucleated  red  blood  cells. 

Hemoconien,  or  Miiller's  blood-dust,  consists  of  small,  round, 
highly  refractive,  colorless  granules  possessing  molecular  move- 
ments and  resembling  fat  droplets. 


388  ABNORMAL    STATES    OF    THE    BLOOD. 

Microscopic  examination  of  the  blood  requires  special  prep- 
aration and  staining  of  the  specimen  to  obtain  the  best  results. 
After  the  drop  of  blood  is  withdrawn  it  should  be  placed  between 
two  perfectly  clean  cover-glasses,  over  each  of  which  it  then  forms 
a  thin  film.  After  drying,  the  specimen  is  fixed  by  heat  (100°  to 
110°  C.)  in  a  copper-box  or  blood  oven  for  a  half -hour  or  more, 
or  by  being  placed  in  a  mixture  of  equal  parts  of  absolute  alcohol 
and  ether  for  about  fifteen  minutes.  It  may  then  be  conveni- 
ently stained  by  immersion  for  a  few  minutes  in  a  diluted  i  per 
cent,  alcoholic  solution  of  eosin.  The  excess  of  the  stain  is  re- 
moved by  washing  the  cover-slip  in  water,  after  which  it  is 
counterstained  with  Delafield's  hematoxylin  solution  for  one 
minute.  The  specimen  is  again  washed  in  water,  dried,  and 
mounted. 

Ehrlich's  triple  stain  may  be  employed  instead.  It  is  made  up 
as  follows :  Saturated  aqueous  solution  of  orange  G.,  40  c.c, ;  satu- 
rated aqueous  solution  of  acid  fuchsin,  45  c.c;  saturated 
aqueous  solution  of  methyl-green,  55  c.c;  these  are  mixed  to- 
gether and  to  this  mixture  added  distilled  water,  50  c.c. ;  alcohol, 
50  c.c. ;  glycerin,  15  c.c.  The  entire  mixture  should  be  kept  in 
a  cool,  dark  place  for  a  week  before  being  used.  When  stained 
with  this  solution  the  red  cells  assume  an  orange  tint,  the  nuclei 
of  the  white  cells  appear  greenish  blue,  the  neutrophilic  granules 
are  colored  vioiet,  and  the  eosmophilic  granules  are  red. 

ABNORMAL  STATES   OF  THE  BLOOD. 

Oligocythemia  is  the  term  applied  to  diminution  in  the  number 
of  red  blood  cells  irrespective  of  the  cause. 

Oligochromemia  consists  in  a  deficiency  in  the  hemoglobin. 
It  is  usually  proportionate  to  the  reduction  in  the  red  blood  cells 
except  in  chlorosis,  in  which  the  hemoglobin  equivalent  of  each 
cell  is  greatly  reduced,  and  pernicious  anemia  in  which  it  is 
relatively  high. 

Leukocytosis  is  an  increase  in  the  number  of  white  blood 
cells  with  an  excess  of  the  polynuclear  forms.  It  may  be  en- 
countered as  a  physiologic  process  in  pregnancy  and  parturition, 


Fig.  42. — Chief  varieties  of  cells  encountered  in  health  and  disease  (Wright's  stain). 
I.  Normal  red  cell.  2.  Common  form  of  polymorphonuclear  leukocyte.  3.  Lesser 
lymphocyte.  4.  Eosinophilic  myelocyte.  5.  Eosinophilic  leukocyte.  6-6.  Neutrophilic 
leukocytes:  upper  left,  transitional  form,  on  right  neutrophilic  myelocytes.  7-7.  Large 
lymphocytes.  8.  Normoblast.  8.  Normoblast  showing  division  of  nucleus.  9.  Normo- 
blast nucleus,  lo-ii.  Basophilic  leukocytes.  12.  Megaloblast.  {From  Greene's  Medical 
Diagnosis.) 

[As  the  formula  for  Wright's  stain  is  complicated,  it  is  advisable  to  purchase  the 
solution  ready  made  from  a  reliable  drug  house,] 


(To  face  page  .38 


ABNORMAL  STATES  OF  THE  BLOOU.  389 

in  the  new-born,  during  digestion,  and  after  ])hysical  exertion. 
It  is  observed  as  a  pathologic  condition  in  leukemia,  pernicious 
anemia,  chlorosis,  diseases  of  the  lympathic  glands,  inflammatory 
conditions  associated  with  exudation,  many  of  the  infectious 
fevers,  in  malignant  disease,  in  gout,  uremia,  and  similar  affec- 
tions, after  hemorrhage,  and  just  before  death.  Drugs  such  as 
pilocarpin,  ergotin,  salicylates,  and  antip3^rin,  and  also  tuber- 
culin induce  leukocytosis.  It  is  not  present  in  uncomplicated 
cases  of  influenza,  typhoid  fever,  typhus  fever,  malaria,  measles, 
miliary  tuberculosis,  or  tuberculosis  unassociated  with  cavity- 
formation  or  enlargement   of  the   lymphatic   glands. 

Eosinophilia  is  the  term  applied  to  any  increase  in  the  cells 
containing  eosinophilic  granules.  It  is  observed  in  filariasis, 
trichinosis,  ankylostomiasis,  osteomalacia,  and  certain  skin 
diseases. 

Leukopenia  is  employed  to  designate  a  marked  reduction  in 
the  number  of  white  blood  cells.  It  is  observed  in  pernicious 
anemia. 

Poikilocytosis  is  a  condition  characterized  by  irregularities 
in  the  shape  of  the  red  blood  cells.  They  may  be  oval,  pointed, 
angular,  or  reniform.  It  is  seen  in  pernicious  anemia,  chlorosis, 
and  leukocythemia. 

Microcythemia  or  microcytosis  is  the  term  applied  to  the 
condition  in  which  the  red  blood  cells  are  markedly  reduced 
in  size.     It  accompanies  the  severe  anemias  and  toxemias. 

Macrocythemia  or  macrocytosis  is  the  opposite  condition,  the 
size  of  the  red  blood  cells  being  greater  than  normal.  It  is  asso- 
ciated with  the  severe  forms  of  anemia,  especially  pernicious 
anemia. 

Nucleated  red  blood  cells  are  abnormal  constituents  of  the 
blood  and  are  present  in  the  grave  forms  of  anemia.  Their  va- 
rieties and  characteristics  have  already  been  described. 

Hydremia  is  an  excess  of  the  watery  constituents  of  the  blood, 
with  a  corresponding  decrease  of  the  cellular  elements.  It  is 
present  in  anemia,  in  anasarca,  and  after  the  ingestion  of  fluids 
in  large  quantities. 

Anhydremia  is  a  condition  in  which  the  fluid  portion  of  the 


390  ANEMIA. 

blood  is  greatly  diminished.  It  occurs  after  excessive  drains  on 
the  system  from  any  cause,  as  in  hemorrhage  and  cholera. 

Melanemia  is  a  rare  condition  characterized  by  the  presence 
of  black,  brown,  or  yellow  granules  in  the  blood.  It  is  observed 
in  malaria,  relapsing  fever,  melanosarcoma,  and  Addison's 
disease. 

Lipemia  means  the  presence  of  fat  in  the  blood.  It  may  be 
detected  by  the  microscope  as  minute  fat  globules  or  by  its 
black  coloration  when  stained  with  a  i  per  cent  solution  of 
osmic  acid.  Lipemia  occurs  in  chronic  alcoholism,  chronic 
nephritis,  diabetes,  pulmonary  tuberculosis,  and  after  injuries 
to  the  bone  marrow. 

Parasites  are  encountered  in  the  blood  in  certain  diseases. 
They  may  be  animal  or  vegetable  parasites.  The  principal 
animal  parasites  are  filaria  sanguinis  hominis,  plasmodium  of 
malaria,  and  distoma  hematobium.  The  most  important 
vegetable  parasites  are  tubercle  bacillus,  streptococcus,  staphyl- 
ococcus, spirillum  of  relapsing  fever,  anthrax  bacillus,  typhoid 
bacillus,  bacillus  of  glanders,  colon  bacillus,  and  the  tetanus 
bacillus. 

ANEMIA. 

Definition. — A  diminution  in  the  number  of  red  blood  cor- 
puscles or  the  entire  quantity  of  the  blood  with  alterations  in 
its  more  important  constituents  such  as  albumin  and  hemo- 
globin. It  may  be  local  (ischemia)  or  general  (oligemia),  or 
it  may  be  primary  or  secondary. 

Distinction  between  Primary  and  Secondary  Anemias. — In 
Primary  anemia  the  cause  is  either  entirely  unknown  or,  if 
known,  seems  insufficient  for  so  severe  a  disease;  Secondary 
anemias  are  symptomatic  of  some  other  disease  or  injury  (gen- 
erally due  to  hemorrhages,  poisons,  or  infectious  diseases). 

Causes. — The  predisposing  causes  are  female  sex,  pregnancy, 
menopause,  heredity,  and  concealed  foci  of  tuberculosis.  The 
exciting  causes  are  deficient  food,  air,  or  sunshine,  excessive 
work,     mental    shock    and    anxiety,    prolonged    and    frequent 


ANEMIA.  391 

nocturnal  emissions,  excessive  nursing,  imperfect  nutrition, 
chronic  intestinal  catarrh,  prolonged  discharges,  hemorrhage, 
Bright's  disease,  parasites,  malaria,  syphilis,  cancer,  and  various 
toxemias. 

Pathologic  Anatomy. — The  blood  is  lighter  in  color,  due  to  the 
reduction  in  the  red  cells  and  hemoglobin.  It  is  thinner  than 
normal  and  coagulates  slowly  and  imperfectly  on  account  of  the 
diminution  in  the  fibrino-plastic  constituent.  After  death  the 
tissues  are  thin,  shrunken,  and  bloodless,  and  if  the  anemia  has 
been  of  long  duration  patches  of  fatty  degenieration  will  be 
observed  in  the  various  organs. 

Symptoms. — Pallor  of  the  skin  and  various  mucous  mem- 
branes is  marked.  Muscular  weakness  and  loss  of  strength  are 
present.  Febrile  paroxysms  are  not  uncommon.  The  appetite 
is  impaired  and  there  is  imperfect  digestion  with  occasional 
attacks  of  vomiting.  Respiration  is  quickened.  There  are 
also  irritability  of  temper,  vertigo,  swooning,  hysteria,  and 
epileptoid  attacks.  The  pulse  is  rapid  and  full,  and  the  heart 
is  irritable  with  systolic  basic  murmurs.  The  cervical  vessels 
pulsate  and  there  is  a  hum  over  the  jugular  vein.  There  may 
be  extravasations  of  blood  into  the  mucous  membranes.  Noc- 
turnal emissions  in  the  male  and  deficient  menses  in  the  female 
accompany  the  condition.  In  children  marasmus  is  common. 
Edema  of  the  ankles  is  often  present.  In  long-continued  cases, 
symptoms  of  fatty  change  in  the  various  organs  or  gastric  ulcer 
may  appear.  Examination  of  the  blood  reveals  a  reduction 
in  the  number  of  red  cells  with  changes  in  size  and  shape, 
nucleated  blood  cells,  diminution  in  hemoglobin,  and  an  in- 
crease in  the  number  of  white  cells. 

Prognosis. — In  secondary  anemias,  those  in  which  the  cause 
can  be  ascertained  and  promptly  overcome,  the  outlook  is 
favorable  in  the  absence  of  complications  and  degenerative 
changes.  In  the  primary  anemias,  such  as  chlorosis,  pernicious 
anemia,  leukemia,  Hodgkin's  disease,  and  splenic  anemia,  the 
prognosis  is  less  favorable.  These  forms  will  be  fully  described 
later. 

Treatment. — The  cause  should  be  removed  and  rest,  restricted 


392  CHLOROSIS. 

exercise,  fresh  air,  sunlight,  and  a  highly  nutritious  diet  should 
be  advised.  The  various  symptoms  should  be  met  with  suita- 
ble remedies  as  they  arise.  The  tonics  of  most  value  in  this 
condition  are  iron,  arsenic,  quinin,  and  strychnin.  The  car- 
bonate of  iron,  gr.  ii  to  v  (0.13  to  0.32  gm.),-is  most  often  em- 
ployed; but  Blaud's  pill,  Basham's  mixture,  tincture  of  the 
chlorid  of  iron,  or  other  preparations  of  iron  may  be  used. 
Great  care  should  be  exercised  to  prevent  constipation  while 
administering  any  of  the  iron  preparations. 

The  following  alterative  tonic,  known  as  Smith's  (Dr.  A.  H.) 
"four  chlorides,"  is  frequently  of  value: 

I^.      Hydrargyri  chloridi  cor- 

rosivi gr.  j  to  ij  .  065  to  .  13  gm. 

Liq.  arsenici  chloridi .  .  .  .    f  3  j  4.  c.c. 

Tinct.  ferri  chloridi 

Acidi  hydrochlorici  dil.  aa  f  5iv     aa     15.  c.c. 

Syrupi foiv  15.  c.c. 

Aquae q.  s.  ad  f  5vj  180.  c.c. 

M.  S. — One  dessertspoonful  in  a  wineglass  of  water  after  each 
meal. 

Cases  of  anemia  with  weak  stomach  can  take  the  following 
"iron  lemonade"  without  discomfort: 

I^.      Tinct.  ferri  chloridi f  oij  8.  c.c. 

Acid  phosphor,  dil f  5ij  8  .  c.c. 

Syr.  limonis f  5ss  15  .  c.c. 

Aquae ifyij  60.  c.c. 

M.  S. — One  teaspoonful,  well  diluted,  after  meals. 

CHLOROSIS. 

Synonym. — Green  sickness. 

Definition. — A  pronounced  anemia  met  with  chiefly  in  young 
girls  about  the  age  of  puberty,  characterized  by  diminution  in 
the  percentage  of  hemoglobin. 

Causes. — The  exciting  cause  is  unknown.  Puberty,  female 
sex,  overwork,  impure  air,  improper  food,  lack  of  sunshine,  pro- 


CHLOROSIS.  393 

longed  lactation,  menstrual  disorders,  heredity,  emotional 
disturbances,  change  of  climate,  and  constipation  are  important 
predisposing  factors. 

Pathologic  Anatomy. — The  number  of  red  blood  corpuscles  is 
nearly  normal  but  there  is  marked  decrease  in  the  hemoglobin 
sometimes  as  low  as  20  per  cent.  The  body  is  usually  well 
nourished  and  the  subcutaneous  fat  well  distributed.  There  is 
pallor  of  the  organs  and  muscles,  but  there  are  no  alterations 
in  the  spleen,  lymphatic  glands,  or  bone  marrow.  The  circula- 
tory apparatus  is  usually  imperfectly  developed,  the  heart  and 
arteries  being  congenitally  small.  The  genitalia  are  often 
immature. 

Symptoms. — Frequently  the  attention  is  first  called  to  the 
condition  at  the  time  of  some  menstrual  disturbance  such  as 
amenorrhea  or  menorrhagia.  Coincidently,  or  shortly  after 
such  an  attack,  the  complexion  changes,  blondes  becoming 
pallid,  waxy,  and  pufify  without  edema,  while  brunettes  assume 
a  muddy  or  grayish  color  with  bluish  black  rings  under  the 
eyes.  Weakness  and  fatigue  manifest  themselves  on  the 
slightest  exertion.  Shortness  of  breath  is  common.  The  heart 
is  irritable  and  the  pulse  soft  and  full.  The  peripheral  veins 
may  pulsate.  The  patient  experiences  a  change  of  disposition, 
becoming  morose  and  despondent,  hysterical,  or  melancholic. 
The  appetite  is  capricious  and  perverted,  and  digestion  is  im- 
paired. Attacks  of  gastralgia  are  frequent  and  gastric  ulcer 
or  phthisis  may  occur  as  complications.  There  is  no  loss 
of  flesh;  the  patient  on  the  contrary  appears  somewhat  stout. 
The  hands  and  feet  are  often  cold.  The  yellowish-green  tinge 
of  the  skin  is  characteristic.  Functional  cardiac  murmurs 
may  be  detected  and  a  hum  may  be  heard  over  the  jugular 
vein  especially  the  right.  Febrile  attacks  are  not  infrequent. 
Headache  and  neuralgia  may  also  be  present.  Constipation 
is  a  common  accompaniment. 

Examination  of  the  blood  shows  a  decrease  in  quality  and 
quantity  of  the  hemoglobin,  resulting  in  the  blood  being  paler 
than  normal.  The  red  corpuscles  are  also  lighter  in  color 
and  show  less  tendency  to  form  rouleaux;  their  character  also 


394 


CHLOROSIS. 


changes,  not  all  being  of  uniform  size,  some  normal,  others 
small  (microcytes),  others  unusually  large  (macrocytes) ,  others 
irregularly  shaped  (poikilocytes).  The  number  may  be  normal 
4,500,000  to  the  cubic  millimeter,  or  it  may  be  occasionally  in- 
creased,  but   it  is  sometimes  lessened,  there  being  as   few  as 


A. 


Fig.  43 — A,  Normal  blood.  B,  Chlorosis.  C,  Pernicious  anemia.  The  plate  shows 
the  sharp  contrast  between  cells  normally  rich  in  hemoglobin  and  the  light  cell  of 
chlorosis  and  also  the  poikilocytosis  and  marked  variation  in  size  noted  in  pernicious 
anemia.  (A  normoblast  and  megaloblast  also  appear.)  Stained  smears.  {Greene's 
Medical  Diagnosis .) 


3,000,000  or  rarely  2,000,000.  The  white  corpuscles  are 
usually  normal  in  number,  but  in  some  instances  their  num- 
ber is  increased  (leukocytosis).  Rarely  granular  bodies  are 
found  in  blood  which  are  generally  regarded  as  the  products  of 
the  degeneration  of  the  white  blood  corpuscles. 


CHLOROSIS.  395 

Complications. — The  principal  complications  are  gastric  ulcer, 
phthisis,  menstrual  disorders,  gastroptosis,  and  venous  throm- 
bosis. 

Diagnosis. — An  examination  of  the  blood  usually  renders  the 
diagnosis  very  easy;  but  if  impracticable  for  any  reason,  the  pe- 
culiar color  in  young  girls  associated  with  weakness  and  various 
functional  disorders  should  lead  one  to  suspect  the  presence  of 
chlorosis  and  treat  accordingly.  Tuberculosis,  peptic  ulcer, 
lead-poisoning,  nephritis,  etc.,  may  be  distinguished  from  it 
by  exclusion. 

Prognosis. — This  is  generally  favorable  under  proper  treat- 
ment; but  some  time  is  necessary  to  effect  a  cure. 

Treatment. — The  unhygienic  surroundings  that  usually  attend 
these  cases  should  receive  attention.  The  quality  of  the  food 
should  be  improved  and  the  patient  should  receive  an  abun- 
dance of  fresh  air  and  sunshine,  and  regulated  exercise  should 
be  advised.  Work  should  be  interdicted.  Rest  in  bed  is  very 
desirable.  Iron  should  be  administered  in  some  form,  being 
careful  to  guard  against  its  constipating  effect  by  the  use  of 
some  laxative.  The  tincture  of  the  chlorid  of  iron  is  usually 
employed. 

An  iron  pill  that  has  been  successfully  used  is: 

I^.     Massae  ferri  carb gr.  xlviij  3 .       gm. 

Potassii  sulph gr.  xxxiv  2 .        gm. 

Potassii  carb gr.  v  i  /3  .^^  gm. 

Pulv.  altheae gr.  iss.  .02  gm. 

Pulv.  acaciae q.  s.  q.  s. 

Ft.  pil  No.  xvj,  and  inclose  in  gelatin  capsules. 
M.  S. — One  three  times  daily. 

The  following  is  Blaud's  formula: 

J^.     Pulv.  ferri  sulph. 

Potassii  carbonat aaBss  aa  15  .  gm. 

Tragacanthae q.  s. 

Ft.  pil  No.  xcvj. 

M.  S. — One  to  3  or  4  pills  three  times  daily. 


396  PROGRESSIVE    PERNICIOUS   ANEMIA. 

The  addition  of  arsenic  is  necessary  in  some  cases.  The  fol- 
lowing formula  is  valuable  under  such  circumstances: 

I^.      Ferri   arsenatis gr.  i/i2toi/6    .  005  to  .011  gm. 

Ext.  nucis  vomicae.  .  .  .    gr.  1/6    to  1/4    .oiito.or6  gm. 
Ft.  pil  No.  j. 
M.  S. — After  meals. 

Or— 

]^.      Liq.  arsenici  chloridi .  .  .  .    f  oij  8.  c.c. 

Tinct.  ferri  chloridi.  ....    f  ovij  28.  c.c. 

Glycerini f  Sj  30.  c.c. 

Elix.  aurantii.  .  .q.  s.  ad.    f  5iij  90.  c.c. 

M.  S. — One  teaspoonful  after  meals,  in  water. 

The  saline  laxatives  and  the  alkaline  mineral  waters  are  useful 
adjuncts  to  the  treatment.  Dilute  hydrochloric  acid,  mangan- 
ese, and  phosphorus  may  also  be  employed.  The  blood  should 
be  examined  from  time  to  time  in  order  to  note  the  effects  of 
treatment. 

PROGRESSIVE    PERNICIOUS    ANEMIA. 

Synonyms. — Idiopathic  anemia;  essential  anemia. 

Definition. — A  progressive,  pernicious  form  of  anemia,  in 
which  the  red  cells  are  specially  diminished  in  number,  of 
unknown  cause,  usually  resisting  all  treatment,  and  toward  its 
termination  associated  with  fever. 

Causes. — The  exciting  cause  of  the  disease  is  unknown.  It 
probably  results  from  the  action  of  some  toxin  generated  in  the 
digestive  tract.  Pregnancy,  syphilis,  intense  mental  anxiety 
and  worry,  middle  life,  and  male  sex  seem  to  predispose  toward 
this  affection.  In  some  it  is  considered  a  hemolysis.  Intestinal 
parasites  (bothriocephalus  latus  and  ankylostomum  duodenale) 
are  responsible  for  some  cases. 

Pathologic  Anatomy. — The  blood  is  scanty  and  pale,  with 
alterations  in  the  size,  shape,  and  number  of  the  red  blood  cells 
and   diminished   hemoglobin.      It   coagulates   very   slowly   and 


PROGRESSIVE    PERNICIOUS   ANEMIA.  397 

imperfectly.  There  is  no  increase  in  the  white  corpuscles. 
The  bone  marrow  becomes  fetal,  red,  and  adenoid  in  character 
containing  nucleated  red  blood  cells,  macroblasts,  neutrophiles. 
and  eosinophiles.  There  is  a  deposition  of  iron  pigment  in  the 
liver  cells  and  those  of  the  spleen.  The  heart,  larger  arteries, 
liver,  spleen,  kidneys,  stomach,  and  muscles  exhibit  circum- 
scribed or  diffused  fatty  degeneration.  There  is  not  much 
emaciation,  although  pallor  of  the  surface  of  the  body  is  pro- 
nounced. The  muscles  are  often  unusually  red.  Changes  in 
the  ganglion  cells  of  the  sympathetic,  sclerosis  of  the  posterior 
columns  of  the  cord,  softening  of  the  lumbar  segment,  and 
atrophy  of  the  gastric  mucous  membrane  may  be  encountered 
coincidently.  Hemorrhages  into  the  skin,  mucous  membranes, 
and  retina  may  also  be  observed. 

Symptoms. — The  affection  begins  insidiously  with  increasing 
languor  and  pallor,  the  muscular  weakness  compelling  the 
patient  to  take  to  his  bed.  Cardiac  palpitation,  dyspnea, 
attacks  of  syncope,  edema,  and  swelling  of  the  ankles  follow. 
Petechial  hemorrhages  scattered  irregularly  over  the  body 
surface  make  their  appearance-  and  there  is  often  tenderness 
over  the  sternum  and  other  superficial  bones.  The  weakness 
progresses  but  emaciation  is  absent.  The  pulse  is  large,  soft, 
and  jerky;  nervous  pulsations  are  observed;  and  hemic  mur- 
murs are  often  heard.  There  is  loss  of  appetite,  and  nausea, 
vomiting,  and  diarrhea  may  occur.  Disorders  of  vision  are 
not  uncommon  and  are  due  to  retinal  hemorrhages.  As  the 
disease  progresses,  a  remittent  form  of  fever  develops,  the 
temperature  frequently  rising  to  102°  to  104°  F. 

Blood  Changes. — The  number  of  red  blood  cells  is  decidedly 
reduced,  sometimes  it  is  as  low  as  500,000  per  cm.  but  the 
hemoglobin  is  not  correspondingly  diminished  although  its  en- 
tire quantity  is  considerably  less  than  normal.  The  red  cells 
show  marked  alterations  in  size,  shape,  and  characteristics. 
They  may  be  large  and  ovoid  (megalocytes)  or  they  may  be 
small,  round,  and  of  a  deep  red  color  (microcytes).  Some  of 
the  red  corpuscles  are  markedly  irregular  and  to  these  the 
term,   "  poikilocytes "  is  applied.      Nucleated  red  cells   (normo- 


398  LEUKOCYTHEMIA. 

blasts  and  megaloblasts)  are  almost  constantly  present.  The 
blood  plaques  are  scanty  or  absent.  The  leukocytes  are  usually 
normal  or  slightly  diminished  with  a  relative  increase  in  the 
small  mononuclear  forms.  Eichhorst's  corpuscles  may  be 
encountered. 

Diagnosis. — The  microscopic  examination  of  the  blood, 
showing  the  marked  vafiations  in  size,  shape,  and  characteristics, 
and  the  enormous  reduction  in  the  number  of  the  red  cells 
serves  to  make  the  diagnosis  in  all  cases,  as  the  symptoms  while 
suggestive  are  by  no  means  conclusive  since  they  are  more  or 
less  common  to  other  form.s  of  anem^ia. 

Prognosis. — The  disease  terminates  in  death  usually  within 
one  or  two  years  after  its  recognition.  Remissions  are  com- 
mon. Recovery  may  occur  in  parasitic  forms  of  the  disease 
on  removal  of  the  cause. 

Treatment. — The  treatment  is  unsatisfactory.  Rest  in  bed, 
fresh  air,  good  food,  salt  baths,  massage,  and  similar  hygienic 
measures  should  be  prescribed.  Arsenic  is  of  value  as  it  seems 
to  check  the  progress  of  the  affection.  It  should  be  adminis- 
tered to  the  point  of  tolerance.  Iron  should  also  be  given  alone 
or  combined  with  arsenic.  Inhalations  of  oxygen  are  recom- 
mended and  bone  marrow  is  sometimes  employed  internally. 
When  due  to  intestinal  parasites,  anthelmintics  should  be 
administered. 

LEUKOCYTHEMIA. 

Synonym. — Leukemia . 

Definition. — A  condition  in  which  there  is  an  enormous 
increase  in  the  number  of  white  blood  corpuscles,  with  enlarge- 
ment of  the  lymphatic  glands,  spleen,  and  often  of  the  bone 
marrow — viz. :  splenic,  lymphaHc,  or  myelogenic,  and  is  character- 
ized by  symptoms  of  pronounced  anemia. 

Causes. — The  true  cause  of  the  disease  is  unknown.  It  occurs 
with  greatest  frequency  in  middle-aged  males  and  is  believed 
to  be  influenced  by  heredity,  traumatism,  and  syphilis.  By 
some  observers  it  is  considered  to  be  of  infectious  origin;  but 
this  view  lacks  confirmation. 


LEUKOCYTHEMIA.  399 

Pathologic  Anatomy. — The  morbid  anatomy  of  leukemia  in- 
cludes alterations  in  the  blood,  the  spleen,  the  lymphatic  glands, 
and  the  bone  marrow.  According  to  the  predominance  of  the 
organic  lesions,  it  is  termed  splenic,  lymphatic,  or  myelogenic. 
Most     cases,    however,    are    combinations    of    these    varieties. 

The  spleen  is  increased  in  size,  density,  and  firmness,  and 
shows  hyperplasia  of  its  lymphoid  struct^  re.  The  organ  may  be 
adherent  to  neighboring  structures  and  is  often  the  seat  of 
lymphoid  tumors.  The  liver  is  also  enlarged  and  infiltrated 
with  leukocytes.  The  lymphatic  glands  all  over  the  body  en- 
large but  are  soft  to  the  touch,  often  fluctuating  and  movable, 
The  solitary  glands,  Peyer's  patches,  the  tonsils,  and  the  lymph- 
follicles  of  the  tongue,  pharynx,  and  mouth  may  partake  of 
similar  alterations.  The  red  bone  marrow  reverts  to  the  em- 
bryonal type.  Its  color  becomes  greenish  yellow  and  the  fat 
disappears.  The  microscope  will  reveal  large  numbers  of  nu- 
cleated red  blood  cells  in  varying  stages  of  development,  poly- 
nuclear  and  mononuclear  leukocytes,  eosinophiles,  and  large 
neutrophiles  with  single  nuclei  (myelocytes).  The  blood  is 
paler  than  normal;  its  specific  gravity  is  reduced  to  1,040  or 
lower;  the  white  cells  are  increased  in  number  and  size; 
and  the  red  corpuscles  are  reduced  in  number  and  size. 

Symptoms.^The  onset  is  insidious  and  in  the  early  stages  the 
manifestations  are  identical  with  those  of  simple  anemia.  There 
is  also  swelling  of  the  abdomen  and  a  feeling  of  fullness  and  pain 
in  the  region  of  the  spleen  due  to  enlargement  of  that  organ.  In 
the  lymphatic  variety  there  is  enlargement  of  the  glands  with 
pallor  of  the  body  surface.  In  the  myelogenic  variety,  the  bones, 
especially  the  ribs  and  sternum,  are  tender  on  pressure  and  the 
patient  assumes  a  waxy  appearance.  The  liver  and  spleen  are 
enlarged  and  moderate  fever  may  be  present.  In  all  varieties, 
emaciation,  weakness,  loss  of  appetite,  feeble  digestion,  diarrhea, 
cardiac  palpitation,  dyspnea,  and  edema  of  the  ankles  and  eye- 
lids are  observed.  Hemorrhages  into  the  skin  or  from  the 
mucous  membranes  may  be  early  symptoms  or  may  occur  near 
the  termination  of  the  disease.  Priapism  is  an  occasional 
manifestation  of  this  disease.     The  urine  is  high-colored,  scanty, 


400  LEUKOCYTHEMIA. 

of  high  specific  gravity  (1,020  to  1,030),  and  often  slightly  al- 
buminous. 

The  Blood. — The  blood  is  pale  and  watery  and  the  white 
blood  corpuscles  are  enormously  increased  in  number.  The 
leukoc3^tes  in  some  cases  equal  the  red  blood  cells  in  number. 
There  is  also  a  reduction  in  the  entire  number  of  blood  cells. 
The  blood  coagulates  slowly,  and  its-  specific  gravity  and  alkalin- 
ity are  subnormal.  The  addition  of  a  drop  of  dilute  gentian- 
violet  solution  stains  the  white  cells  blue  and  they  may  then  be 
readily  detected.  Nucleated  red  cells  and  poikilocytes  are  pres- 
ent and  the  hemoglobin  is  diminished.  Blood  plaques  are  some- 
what increased.  Charcot's  crystals  are  often  present.  In  spleno- 
inyelogenous  leukefnia  the  small  mononuclear  leukocytes  are 
relatively  increased.  The  proportion  of  eosinophiles  is  unchanged. 
The  polynuclear  neutrophiles  undergo  marked  alterations  in  size, 
but  their  proportion  usually  remains  normal.  The  characteris- 
tics of  this  form  are  the  cells  derived  from  the  bone  marrow 
(myelocytes)  containing  neutrophilic  granules,  and  large  mono- 
nuclear cells  containing  karyokinetic  figures.  Polynuclear 
basophilic  cells  are  constantly  present  in  great  numbers.  Nucle- 
ated red  cells  (gigantoblasts)  and  cells  with  fragmented  nuclei 
may  be  encountered.  Lymphatic  leukeryiia  is  rare  and  may  be 
acute  or  chronic  in  form.  The  acute  form  occurs  usually  in 
children  and  is  attended  by  lymphatic  enlargement,  hemor- 
rhages, and  the  presence  of  large  pale  lymphocytes  in  excess  in 
the  blood.  The  chronic  form  is  characterized  by  an  increase  of 
the  white  blood  cells,  but  to  a  less  extent  than  the  splenic  va- 
rietv  of  the  disease.  The  small  lymphocytes  are  affected 
especially  by  this  increase,  the  other  forms  of-  leukocytes  being 
relativel}^  diminished.  Eosinophiles,  myelocytes,  and  nucleated 
red  cells  are  rarely  present. 

Diagnosis. — As  in  other  affections  associated  with  symptoms 
of  anemia,  microscopic  examination  of  the  blood  is  absolutely 
necessary  to  determine  the  true  nature  of  the  disease.  The 
enormous  increase  in  the  white  cells  with  changes  in  their  size, 
characteristics,  and  proportion,  and  the  presence  of  new  cellular 
elements  in  the  blood  are  the  distinctive  features.      Leukocytosis 


hodgkin's  disease.  401 

is  attended  primarily  by  an  increase  of  the  white  cells,  but  this 
increase  is  not  so  great  as  in  leukemia  and  affects  chiefly  the 
polymorphonuclear  neutrophiles.  The  variations  in  the  charac- 
teristics of  the  cells  will  aid  in  distinguishing  the  varieties  of 
leukemia  one  from  the  other. 

Prognosis. — Acute  leukemia  terminates  fatally  within  two 
or  three  months;  the  other  forms  seldom  last  more  than  two  or 
three  years  and  also  end  in  death. 

Treatment. — While  seldom  satisfactory,  the  various  symp- 
toms should  be  treated  as  they  arise,  on  general  therapeutic 
principles.  Rest,  nutritious  diet,  fresh  air,  sunshine,  and  cod- 
liver  oil,  hypophosphites,  iron,  quinin,  strychnin,  arsenic,  ergot, 
or  oxygen  should  be  prescribed.  Recently  the  Roentgen  ray 
has  been  employed  in  the  treatment  of  this  disease;  and  if 
carried  out  carefully  and  systematically,  this  form  of  treatment 
should  be  at  least  as  satisfactory  as  the  other  and  older  (unsatis- 
factory) remedies. 

HODGKIN'S  DISEASE. 

Synonyms. — Pseudoleukemia;  pseudoleukocythemia;  lym- 
phatic anemia;  lymphadenoma. 

Definition. — An  affection  characterized  by  hypertrophy  of 
the  lymphatic  glands  in  various  parts  of  the  body,  associated 
v/ith  marked  anemia. 

Cause. — Unknown. 

Pathologic  Anatomy. — A  hyperplasia  of  the  lymph  glands 
interfering  more  or  less  with  their  functions.  The  enlargement 
may  be  confined  to  one  isolated  gland,  or  a  number  may  be 
affected  in  different  portions  of  the  body,  or  a  number  in  one 
location  may  be  simultaneously  affected,  causing  a  tumor  vary- 
ing in  size  from  an  egg  to  an  orange  or  even  larger.  The  spleen 
and  liver  are  involved  in  two-thirds  of  the  cases.  "  The  marrow 
of  the  long  bones  may  be  converted  into  a  rich  lymphoid  tissue  " 
(Osier).  The  red  blood  corpuscles  are  decreased  in  number 
8.nd  altered  in  size  and  shape ;  the  white  blood  corpuscles  may  be 
slightly  increased  in  number,  but  there  is  no  approximation  to 
anything  like  leucocythemia. 
26 


402  STATUS   LYMPHATICUS. 

Symptoms. — A  slowly  developing  anemia  with  isolated  or  dif- 
fused enlargement  of  the  lymphatic  glands.  As  the  condition 
develops,  fever  of  a  remittent  character  occurs,  with  feeble 
cardiac  action  and  shortness  of  breath.  Hemorrhages  may 
occur.  The  patient  grows  progressively  worse  with  all  the 
associated  symptoms  of  deficient  blood,  death  occurring  by 
asthenia. 

Diagnosis. — A  study  of  the  clinical  history  will  prevent  error, 
as  tubercular  or  scrofulous  glands  are  accompanied  with  tuber- 
cular changes  elsewhere ;  and  leukemias  do  not  present  the  same 
blood  picture  as  Hodgkin's  disease. 

Prognosis. — Unfavorable.  The  progress  may  be  slow,  but 
it  is  none  the  less  toward  a  fatal  termination.  The  duration 
is  from  two  to  three  years. 

Treatment. — The  treatment  is  that  of  pernicious  anemia. 
Surgical  intervention  is  sometimes  necessary  to  relieve  the  dys- 
pnea.    Radiotherapy  may  be  of  value  in  some  cases. 

STATUS  LYMPHATICUS. 

Synonym. — Lymphatism. 

A  rare  disease  of  the  blood-making  organs  occurring  in  chil- 
dren and  young  persons,  characterized  by  a  hyperplasia  of  the 
lymphoid  tissues  throughout  the  body,  including  the  lymphatic 
glands,  spleen,  thymus  gland,  and  bone  marrow.  The  cause  is 
unknown.  The  symptoms  are  secondary  to  the  nutritional  dis- 
turbances. There  is  a  marked  diminution  of  power  of  resis- 
tance; and  sudden  death,  or  death  from  a  slight  cause  may 
occur.     The  affection  resembles  Hodgkin's  disease  very  closely. 

SPLENIC  ANEMIA. 

Synonym. — Splenic  pseudoleukemia. 

An  anemic  condition  in  which  the  spleen  is  greatly  enlarged 
and  indurated,  and  its  lymphatic  structure  is  destroyed  and 
replaced  by  an  overgrowth  of  the  reticulum.  The  red  blood 
cells  and  hemoglobin  are  diminished.  Microcytes,  megalo- 
cytes,    poikilocytes,    and   numerous   nucleated   red   blood   cor- 


Addison's  disease.  403 

puscles  are  present.  The  leukocytes  are  slightly  increased. 
When  splenic  anemia  is  associated  with  cirrhosis  of  the  liver 
and  ascites,  the  condition  is  known  as  Bantts  disease.  The 
disease  lasts  from  six  months  to  three  years  and  terminates  in 
death.  The  treatment  is  unsatisfactory.  Removal  of  the 
spleen  has  been  followed  by  recovery. 

ADDISON'S   DISEASE. 

Synonym, — The  bronzed-skin  disease. 

Definition. — A  well-marked  constitutional  disease,  char- 
acterized by  extreme  muscular  weakness,  asthenia,  a  tendency 
to  nausea  and  vomiting,  and  an  exaggeration  of  the  normal 
pigmentation  of  the  skin. 

Causes. — Obscure.  Tuberculosis  of  the  suprarenal  capsules 
is  generally  the  cause,  but  scrofula  and  syphilis  have  each 
been  given  as  the  cause.  It  is  usually  encountered  in  middle- 
aged  men. 

Pathologic  Anatomy. — This  includes  (i)  tuberculosis  with 
fibrocaseous  and  calcareous  degeneration;  (2)  cystic  degenera- 
tion; (3)  fatty  degeneration;  (4)  simple  atrophy;  (5)  chronic 
interstitial  inflammation  which  may  lead  to  atrophy;  (6)  ma- 
lignant disease,  including  carcinoma  and  sarcoma;  (7)  hemor- 
rhagic extravasations;  (8)  embolism  (Tyson).  It  is  essentially 
a  disease  of  the  suprarenal  bodies,  generally  tuberculosis;  but 
the  abdominal  sympathetic  system  is  also  often  involved. 

Symptoms. — The  onset  of  the  disease  is  insidious,  with  a  feel- 
ing of  extreme  languor,  muscular  fatigue,  asthenia,  indigestion, 
anorexia,  dyspnea,  cardiac,  palpitation,  vertigo,  melancholia, 
and  excessive  drowsiness.  The  surface  is  first  pale,  then  changes 
to  a  hue  like  that  of  melanemia,  changing  to  icteroid,  finally 
resembling  the  color  of  a  mulatto,  and  then  to  a  lusterless 
bronze.  These  changes  also  occur  on  the  mucous  membrane 
of  the  lips,  tongue,  gums,  and  mouth. 

Prognosis. — An  incurable  disease.      Duration,  a  year  or  two. 

Treatment. — Symptomatic.  Iron  and  arsenic  have  both 
been    recommended,     and    the    administration    of    suprarenal 


404  EXOPHTHALMIC    GOITRE. 

extract,   gr.   iii  to  v,   three  times   daily  has  been  followed  by 
temporary  improvement. 

EXOPHTHALMIC  GOITRE. 

Synonyms. — Graves'  disease;  Basedow's  disease;  Parry's 
disease. 

Definition. — A  disease,  characterized  by  protrusion  of  the 
eyeballs,  enlargement  of  the  thyroid  gland,  rapid  pulse,  palpita- 
tion of  the  heart,  and  tremor. 

Causes. — It  is  probably  due  to  some  perversion  of  function 
or  hyperactivity  of  the  thyroid  gland.  Among  the  exciting 
causes  are  anemia,  shock,  fright,  chagrin,  worry,  and  reverses 
of  fortune.      It  is  more  frequent  in  women  than  in  men. 

Pathologic  Anatomy.- — The  veins  and  arteries  of  the  thyroid 
gland  are  dilated,  the  result  of  a  vasomotor  paralysis.  The 
enlargement  of  the  gland  is  the  result  of  the  dilated  vessels, 
and  a  serous  infiltration  of  its  tissues,  followed,  if  long-continued, 
by  hypertrophy.  A  considerable  increase  of  fat  behind  the 
eyeballs  has  been  observed.  In  the  majority  of  cases  more  or 
less  anemia  exists. 

Symptoms. — The  development  of  the  group  of  symptoms  may 
occur  suddenly,  as  the  result  of  some  great  shock  to  the  nervous 
system,  but  in  the  majority  of  instances  they  develop  slowly  and 
insidiously,  with  cardiac  palpitation,  with  paroxysms  of  more 
marked  acceleration,  or  tachycardia,  the  pulse  rate  varying 
from  90  to  120,  150,  and  rarely  as  high  as  200  beats  per  minute, 
and  soon  pulsations  of  the  vessels  of  the  neck  and  thyroid  gland 
may  be  felt  and  seen.  The  enlargement  of  the  thyroid  gland — 
the  goitre — appears  gradually  after  the  development  of  the 
circulatory  disturbances,  although  rarely  it  may  be  the  first 
symptom  observed.  The  goitre  is  elastic,  rather  soft,  and  has 
a  thrill  similar  to  an  aneurysm.  The  degree  of  enlargement 
varies  in  different  cases,  and  in  none  ever  attains  a  very  great 
size.  Following  the  development  of  the  goitre  occurs  the  pro- 
trusion of  the  eyeball — the  exophthalmos — which  may  be 
confined  to  one  eye,  but  usually  occurs  in  both.     Prominence 


EXOPHTHALMIC    GOITRE.  405 

of  the  eyeball  may  be  the  first  symptom  observed,  but  usually 
it  does  not  develop  until  after  the  appearance  of  the  goitre. 
The  degree  of  protrusion  varies  from  a  slight  staring  expression 
to  a  point  so  great  that  the  eyelids  cannot  cover  the  balls. 
Associated  with  the  protrusion  of  the  eyeballs  is  incoordina- 
tion in  the  movements  of  the  eyelids  and  the  eyeball,  the  sign  of 
Graefe,  so  that  when  the  eyes  are  quickly  cast  down,  the  eyelids 
do  not  follow  them,  the  sclerotic  being  visible  below  the  upper 
lid.  Diminution  in  the  power  of  convergence  during  accommo- 
dation (Moebius'  symptom)  and  widening  of  the  palpebral  angle 
{Stellwags  sign)  may  also  be  present.  Vision  is  unimpaired. 
Conjunctivitis  may  arise,  the  result  of  the  imperfect  protection 
of  the  protruding  ball  by  the  eyelids.  Pulsation  of  the  retinal 
arteries  can  be  seen  with  the  ophthalmoscope. 

Associated  with  the  pathognomonic  symptoms  are  nervous- 
ness, tremor,  irritability  of  temper,  headache,  insomnia,  vertigo, 
fits  of  despondency,  aphonia,  and  cough  the  result  of  pressure 
of  the  goitre,  disorders  of  digestion,  increase  of  temperature, 
anemia,  excessive  sweating,  and  loss  of  flesh. 

Diagnosis. — The  fully-developed  disease  presents  no  diffi- 
culties in  diagnosis,  but  during  its  incipiency,  before  the 
characteristic  symptoms  have  appeared,  the  disease  may  be 
confounded  with  such  conditions  as  cardiac  disease,  neuras- 
thenia, lithemia,  malaria,  or  incipient  phthisis. 

Prognosis. — Recovery  occurs  in  a  fair  number,  but,  as  a  rule, 
the  course  is  slow  and  protracted.  The  disorders  of  the  circu- 
lation lead  to  dilated  heart  in  many  cases,  and  ultimately  death 
occurs  from  this  cause.      Relapses  are  frequent. 

Treatment. — One  of  the  first  injunctions  to  be  placed  on  a 
case  of  exophthalmic  goitre  is  rest,  both  physical  and  mental, 
as  well  as  freedom  from  worry  or  emotional  excitement;  little 
progress  will  be  made  if  this  point  be  neglected.  The  associated 
anemia  requires  the  administration  of  tonics  such  as  iron, 
arsenic,  etc.,  and  nutritious,  easily  digested  food.  To  control 
the  circulatory  disturbances  digitalis  and  strophanthus  (tincture 
of  strophanthus,  nxv  (0.3  c.c),  from  three  to  six  times  daily) 
are   of  inestimable  value.     Silver  nitrate,  gr.  1/8   (0.008  gm.), 


4o6  MYXEDEMA. 

after  meals  is  of  value,  alternating  with  strophanthus  or  digitalis. 
Bartholow  employs  quinin,  ergotin,  and  belladonna,  in  combi- 
nation, and  obtains  beneficial  effects.  Extract  of  thyroid  gland 
has  been  used  with  good  effect  in  3  gr.  (0.2  gm.)  doses  three 
times  daily.  The  initial  dose  of  this  drug  should  always  be 
small.  Galvanism  to  the  cervical  sympathetic  and  pneumo- 
gastric  is  always  a  beneficial  adjunct  to  the  medicinal  treatment. 
Surgical  intervention  may  be  considered  in  the  failure  of  other 
methods  after  a  fair  trial.  The  general  nervousness,  restlessness, 
and  insomnia  will  often  call  for  special  treatment,  when  use  may 
be  made  of  chloral,  potassium  bromid,  sulphonal,  or  trional. 
It  is  better,  however,  not  to  use  this  class  of  drugs  in  a  routine 
manner,  but  for  the  special  indications  only. 

MYXEDEMA. 

Definition. — A  progressive  disease  characterized  by  an 
infiltration  of  the  connective  tissue  with  a  gelatinous  substance, 
general  failure  of  the  health,  and  mental  failure,  due  to  or 
associated  with  atrophy  of  the  thyroid  gland. 

Cretinism  is  considered  akin  to  myxedema,  save  that  it  is  a 
congenital  condition  associated  with  alteration  or  absence  of 
the  thyroid  gland. 

Cachexia  strumipriva,  a  condition  following  the  extirpation 
of  the  thyroid  gland,  especially  in  the  young,  gives  symptoms 
resembling  myxedema. 

Causes. — The  cause  of  the  atrophy  of  the  thyroid  gland  is 
unknown.  It  is  more  frequent  in  women  than  in  men  and 
usually  develops  about  middle  life.  The  disease  is  said  to 
have  followed  the  extirpation  of  the  gland  in  the  adult. 

Morbid  Anatomy. — Atrophy  of  the  thyroid  gland,  sometimes 
more  advanced  in  one  lobe  than  the  other,  is  constant.  "  The 
pituitary  body  has  been  found  increased  in  size"  (Wood). 
Until  the  functions  of  the  thyroid  gland  are  more  fully  under- 
stood, the  steps  in  the  changes  resulting  from  its  atrophy  can 
not  be  explained. 

Symptoms. — The  disease  develops  slowly,  often  a  number  of 
years    elapsing   before    all    the    characteristic    phenomena    are 


MYXEDEMA.  407 

present.  The  face  and  neck,  and  often  other  parts  of  the  body, 
have  a  bloated  appearance.  The  normal  wrinkles  are  obliter- 
ated, the  nose  is  wide  and  thick,  the  lips  thick  and  everted,  the 
mouth  enlarged,  as  is  also  the  tongue,  giving  a  coarse  and 
broadened  or  mask-like  appearance  to  the  features.  The  skin 
is  denser  and  does  not  pit  on  pressure,  but  is  pale  or  chalk-like, 
or  yellowish  white,  with  often  a  small  reddish  patch  on  either 
cheek.  The  expression  of  the  countenance  is  immobile  and 
stupid.  The  hands  and  feet  are  enlarged,  the  skin  is  coarse  and 
dry.  The  shape  of  the  hands  is  changed,  presenting  a  "  spade- 
like" appearance.  The  mental  condition  is  sluggish  and  stupid, 
with  loss  of  memory  and  of  interest  in  the  environments  and 
affairs  of  life.  Occasionally  hallucinations  of  sight  occur.  The 
tendency  is  toward  a  dementia.  Patients  often  complain  of 
neuralgic  pains  and  numbness  and  a  sense  of  muscular  weakness. 
The  temperature  is  always  below  the  normal.  Anemia  develops 
and  often  a  subacute  nephritis  or  a  glycosuria  or  phthisis 
follows. 

Diagnosis. — Dropsy  or  a  general  edema  has  a  superficial 
likeness  to  myxedema,  but  a  study  of  the  symptoms  should 
prevent  error,  as  pitting  on  pressure  does  not  occur  in  myxedema. 

Prognosis. — Under  treatment  a  great  improvement  can  be 
produced,  but  whether  a  permanent  cure  results  is  not  yet  fully 
determined. 

Treatment. — The  body  surface  should  be  protected  from 
cold  by  warm  clothing.  Warm  bathing  followed  by  inunctions 
of  olive  oil  is  also  beneficial.  Warm  climates  are  best  adapted 
for  these  patients.  The  administration  of  thyroid  extract, 
beginning  with  gr.  ss  (0.03  gm.)  after  meals,  gradually  increas- 
ing the  dose  until  several  grains  are  taken  daily  or  until  symp- 
toms of  thyroidism  appear,  is  of  great  value.  The  remedy 
should  be  continued  over  a  long  period  and  withheld  when 
evidences  of  thyroidism  such  as  nervousness,  restlessness,  insom- 
nia, dyspnea,  rapid  pulse,  cardiac  palpitation,  gastrointestinal 
disorders,  confusion  of  mind,  or  delirium  become  manifest. 
The  anemia  and  muscular  weakness  are  overcome  by  the  use 
of  iron,  strychnin  arsenite,  gr.  1/60  (o.ooi  gm.),  and  nuclein. 


4o8  PHYSICAL   DIAGNOSIS. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM. 
PHYSICAL  DIAGNOSIS. 

The  methods  employed  in  making  a  physical  examination  of 
the  heart  are:  I.  Inspection.  II.  Palpation.  III.  Percussion. 
IV.  Ausctiltation. 

The  precordium  is  the  region  overlying  the  heart  and  to  which 
the  physical  examination  is  applied.  It  may  be  unduly  promi- 
nent as  the  result  of  rickets,  cardiac  hypertrophy,  cardiac 
dilatation,  pericardial  effusions,  localized  pleural  effusions, 
empyema,  and  aneurysms.  It  may  be  abnormally  depressed  as 
the  result  of  spinal  curvature,  rickets,  or  the  shrinking  following 
remote  pericarditis  and  empyema.  The  interspaces  bulge  in 
pericardial  effusion  and  are  retracted  when  adhesions  form.  A 
change  in  the  color  of  the  integument  of  the  precordial  region  is 
nearly  always  induced  by  a  purulent  pericardial  or  pleural  effu- 
sion on  the  verge  of  rupture. 

Inspection  serves  to  detect  the  exact  point  of  the  cardiac 
impulse,  and  the  presence  or  absence  of  any  abnormal  pulsations, 
or  any  change  in  the  form  of  the  precordium.  Normally,  the 
impulse  is  visible  only  in  the  fifth  interspace,  midway  between 
the  left  nipple  and  the  left  border  of  the  sternum,  its  area 
covering  about  i  square  inch,  most  distinct  in  the  thin, 
while  often  barely  seen  in  the  very  fleshy;  often  displaced 
downward  by  full  inspiration  and  elevated  by  complete 
expiration. 

The  position,  area,  Sind  force  of  the  impulse  may  be  altered  by 
disease. 

The  position  may  be  moved  to  the  right  by  left-sided  pleural 
effusions,  by  chronic  pulmonary  or  pleural  disease  of  the  right 
side  associated  with  retraction,  and  as  the  result  of  transposition 
of  the  viscera.  Displacement  downward  may  be  caused  by 
cardiac  hypertrophy,  pulmonary  emphysema,  mediastinal 
growths,  and  aneurysm  of  the  arch  of  the  aorta.     It  may  be 


PHYSICAL    DIAGNOSIS.  409 

displaced  upward  by  a  pericardial  effusion  or  abdominal  tumors. 
It  may  be  moved  farther  to  the  left  as  the  result  of  left-sided 
cardiac  hypertrophy  or  dilatation,  retraction  of  the  left  side 
following  chronic  lung  or  pleural  disease,  right-sided  pleural 
effusion,  abdominal  growths,  and  pericardial  effusion. 

The  area  of  the  impulse  is  enlarged  by  pericardial  adhesions, 
cardiac  hypertrophy,  cardiac  dilatation,  and  by  thinning  of 
the  chest  walls  and  shrinking  of  the  lungs  from  any  cause. 
The  area  may  be  diminished  by  pericardial  effusion  and 
emphysema. 

The  force  of  the  impulse  may  be  increased  by  excitement, 
exophthalmic  goitre,  certain  drugs,  various  forms  of  reflex 
irritation,  and  cardiac  hypertrophy.  It  is  relatively  increased 
by  conditions  that  increase  its  area.  It  may  be  decreased  by 
cardiac  dilatation  or  degeneration,  collapse,  pericardial  effusion, 
and  emphysema. 

Abnormal  pulsations  may  be  detected  at  times  by  inspection 
in  the  epigastrium,  at  the  base  of  the  heart,  in  the  left  axillary 
region,  in  the  carotid  arteries,  and  in  the  jugular  vein. 

Pulsation  in  the  epigastrium  may  be  due  to  aneurysm  of  the 
abdominal  aorta,  abdominal  tumors  lying  over  the  aorta,  en- 
largement of  the  right  ventricle,  and  cardiac  excitement  from 
any  cause. 

Basic  pulsation  is  usually  produced  by  aneurysm  of  the  arch 
of  the  aorta  or  cardiac  hypertrophy. 

Axillary  pulsation  (left  side)  may  be  caused  by  cardiac  en- 
largement, pulsating  empyema,  retraction  of  the  left  side  of  the 
chest,  and  aneurysm. 

Abnormal  pulsation  of  the  carotid  arteries  may  be  due  to 
exophthalmic  goitre,  anemia,  cardiac  excitement,  neurotic 
temperament,  aortic  regurgitation,  and  disease  of  the  vessel 
walls. 

Jugular  pulsation  may  be  induced  by  coughing,  forced  expira- 
tion, pericardial  adhesions,  and  tricuspid  regurgitation. 

Palpation  confirms  the  observations  of  inspection,  and  also  de- 
termines the  force,  frequency,  and  regularity  of  the  cardiac 
impulse. 


41 0  PHYSICAL   DIAGNOSIS. 

The  force  of  the  impulse  is  diminished  by  cardiac  dilatation, 
fatty  and  fibroid  degenerations  of  the  heart,  emphysema,  peri- 
cardial effusion,  and  adynamic  diseases.  The  impulse  is 
increased  by  cardiac  hypertrophy,  during  the  first  stage  of  endo- 
carditis and  pericarditis,  functional  cardiac  disturbances,  and 
sthenic  inflammations. 

Palpation  also  serves  to  detect  the  shock  induced  by  the 
closure  of  the  valves.  It  is  most  marked  in  persons  having  thin 
chest  walls  and  in  whom  for  any  reason  there  is  heightened 
tension  either  in  the  aorta  or  in  the  pulmonary  artery. 

Thrills  may  be  also  recognized  by  palpation  and  are  produced 
by  vibration  of  the  blood  in  passing  over  a  rough  surface.  A 
thrill  is  created  only  at  the  time  the  blood  is  passing  through  the 
orifices  and  is  usually  felt  at  the  apex.  A  thrill  or  tremor  ob- 
tained by  palpation  in  this  area  is  usually  indicative  of  mitral 
obstruction.  The  apical  thrill  is  presystolic  in  time.  A  thrill 
(systolic  in  time)  at  the  second  right  costal  cartilage  is  symptom- 
atic of  aortic  obstruction.  A  systolic  thrill  at  the  second  left 
costal  cartilage  points  to  pulmonary  obstruction. 

Pericardial  friction  may  be  detected  by  palpation.  It  has  a 
to  and  fro  movement,  synchronous  with  the  heart's  action,  and 
bears  no  relation  to  respiration. 

Position  of  the  patient  often  alters  the  intensity  of  these  ab- 
normal phenomena.  The  upright  posture,  or  slightly  leaning 
forward  serves  to  intensify  friction,  fremitus,  and  thrills. 

Percussion  will  determine  the  boundaries  of  the  superficial 
and  deep  cardiac  space,  the  so-called  precordium. 

The  superficial  cardiac  space  is  that  portion  of  the  heart  not 
covered  by  the  lung  at  the  time  of  inspiration  and  extends  from 
_the  fourth  to  the  sixth  costal  cartilages  and  from  the  left  border 
of  the  sternum  to  the  apex  beat.  Its  configuration  is  conse- 
quently triangular.  This  superficial  area  of  dullness  is  increased 
by  cardiac  hypertrophy,  cardiac  dilatation,  and  pericardial 
effusion;  it  is  diminished  at  the  end  of  full  inspiration,  in  emphy- 
sema, when  the  heart  is  retracted  by  pericardial  or  pleural 
adhesions,  and  when  air  is  present  in  the  pericardial  or  pleural 
sac. 


PHYSICAL   DIAGNOSIS.  4II 

The  deep  cardiac  space  (precordium)  extends  from  the  third 
left  costosternal  junction  to  the  apex  beat;  from  thence  to  the 
junction  of  the  xiphoid  cartilage  with  the  sternum,  the  base  of 
the  triangle  being  formed  by  a  line  1/2  inch  from  and  par- 
allel with  the  right  border  of  the  sternum.  This  area  is  in- 
creased by  hypertrophy  or  dilatation  of  the  heart  and  pericar- 
dial effusions.  It  is  apparently  increased  by  shrinking  of  the 
lungs  as  in  phthisis  and  in  consolidation  of  the  anterior  border 
of  the  investing  lung.  It  may  be  diminished  in  emphysema 
and  by  the  presence  of  air  in  the  pleural  or  pericardial  sacs. 

Auscultation  indicates  the  character  of  the  normal  cardiac 
sounds  and  the  point  at  which  they  are  heard  with  greatest  in- 
tensity, and  should  be  thoroughly  understood  if  abnormal 
sounds  are  to  be  fully  appreciated. 

The  ear  or  stethoscope  applied  to  the  precordium  distin- 
guishes in  health  two  sounds,  separated  by  a  momentary  silence 
— the  short  pause,  and  the  second  sound  followed  by  an  interval 
of  silence — the  long  pause. 

The  first  sound,  corresponding  to  the  contraction  of  the  heart 
— systole — is  louder,  longer,  and  of  a  lower  pitch  and  a  more 
booming  quality  than  the  second  sound,  and  has  its  point  of 
greatest  intensity  at  the  cardiac  apex  or  a  little  to  the  left. 
It  corresponds  closely  in  time  to  the  pulsations  as  felt  in  the 
carotid  or  radial  arteries. 

The  second  sound  is  shorter,  weaker,  and  higher  in  pitch  than 
the  first  sound,  and  has  a  clicking  or  valvular  quality,  having 
its  point  of  greatest  intensity  at  the  second  right  costal  cartilage 
and  a  little  above,  and  corresponds  to  the  closure  of  the  aortic 
and  pulmonary  valves.  The  sound  made  by  the  closure  of  the 
tricuspid  valves  is  best  isolated  at  the  ensiform  cartilage;  the 
sound  made  by  the  closure  of  the  pulmonary  valves,  at  the  third 
left  costal  cartilage. 

The  following  table,  giving  the  phenomena  and  time  of  nor- 
mal cardiac  movements,  will  assist  in  recalling  the  physiology 
of  the  heart:? 


412 


PHYSICAL   DIAGNOSIS. 


Action  of  heart. 


Sound  and 
pause. 


Time  in  one- 
tenths  of  the 
heart's  beats. 


Systole  of  the 
heart,  or  ven- 
tricular sys- 
tole. 


Diastole  of  the 
heart,  or  ven- 
tricular dias- 
tole. 


Ventricles  contracting,  auricles  dilating. 

Auriculo-ventricular  valves  (mitral  and 
tricuspid)  suddenly  close  and  remain 
closed  during  the  whole  time  of  the 
first  sound. 

Semilunar  valves  (aortic  and  pulmon- 
ary) open;  movement  or  locomotion  of 
heart  causing  the  impulse  or  apex  beat. 

Blood  rushes  out  from  the  ventricles  into 
aorta  and  pulmonary  artery,  and 
dilates  these  vessels  and  their  exten- 
sions (arterial  system). 

Blood  flows  slowly  into  the  auricles 
from  the  vena  cava  and  pulmonary 
veins. 

The  pulse  felt  in  different  arteries  from 
one-thirtieth  to  one-eighth  of  a  second 
later  than  impulse. 


Ventricles  dilating  and  receiving  blood 
from  auricles.  Auricles  dilating  and 
receiving  blood  from  veins. 

Auriculo-ventricular  valves  (mitral  and 
tricuspid)  open. 

Dilated  pulmonary  artery  and  aorta 
recoil  and  suddenly  close  the  semilunar 
valves  (aortic  and  pulmonic),  which 
remain  closed  during  the  whole  of  the 
second  sound  and  the  interval  of 
silence. 

Ventricles  and  auricles  still  continue  to 
dilate — viz.,  receive  blood.  Near  the 
close  of  this  period  the  auricles,  being 
fully  dilated  (filled  with  blood),  sud- 
denly contract  and  complete  the  dila- 
tation of  the  ventricles. 


First  cardiac 
sound  (sys- 
tolic) dull 
and  pro- 
longed. 


About  four- 
tenths  of 
the  heart's 
beats  or 
t  w  e  n  t  y- 
f  o  u  r-s  i  X- 
tieths  of  a 
second. 


Second    car-    About  three- 
diac    sound       tenths       of 


(diastole) 
short      and 
sharp. 


Period 
silence 
rest. 


of' 
or 


the  heart's 
beats,  or 
e  i  g  h  t  e  en- 
sixtieths  of 
a  second. 


About  three- 
tenths  of 
the  heart's 
beats,  or 
eight  een- 
sixtieths  of 
a  second. 


The  extent  of  surface,  over  which  the  cardiac  sounds  are 
heard,  varies  according  to  the  size  of  the  heart  and  the  condi- 
tion of  the  adjacent  organs  for  transmitting  sounds. 

The  cardiac  sounds  may  be  altered  in  intensity,  qttality,  pitch, 
seat,  and  rhythm,  or  they  may  be  accompanied,  preceded,  or 
followed  by  adventitious  or  new  sounds,  the  so-called  endo- 
cardial or  cardiac  murmurs. 

The  intensity  is  increased  by  cardiac  hypertrophy,  irritability 
of    the    heart,    or    consolidation    of    adjacent    lung-structure. 

The  intensity  is  diminished  by  cardiac  dilatation  or  degenera- 


PHYSICAL    DIAGNOSIS.  4^3 

tion,  pericardial  effusion,  or  emphysematous  lung  overlapping 
the  heart,   and  during  the  course  of  adynamic  fevers. 

The  quality  and  pitch  of  the  first  sound  may  be  sharp  or 
short  and  of  higher  pitch  when  the  ventricular  walls  are  thin, 
or  have  undergone  fibroid  change,  the  valves  being  normal; 
its  pitch  and  quality  are  also  raised  during  the  course  of  low 
fevers.  The  second  sound  becomes  duller  and  lower  in  pitch 
when  the  elasticity  of  the  aorta  is  diminished  or  the  aortic 
valves  thickened.  Either  or  both  sounds  have  a  more  or  less 
metallic  quality  in  irritable  heart  and  during  gaseous  distention 
of  the  stomach. 

The  seat  of  greatest  intensity  of  the  cardiac  sounds  is  changed 
by  displacement  of  the  heart,  pleuritic  effusion,  emphysematous 
lung  overlapping  the  heart,  pericardial  effusion,  and  abdominal 
tympanites. 

The  rhythm  is  often  interrupted  by  a  sudden  pause  or  silence, 
the  heart  missing  a  beat,  or  the  sounds  are  irregular,  confused, 
and  tumultuous,  as  the  result  of  organic  changes  in  the  cardiac 
muscle,  valves,  orifices,  or  vessels.  A  reduplication  of  one  or 
both  sounds  of  the  heart  may  occur. 

The  adventitious  cardiac  sotinds  or  rnurmurs  are  of  two  kinds: 
those  produced  external  to  the  heart,  as  pericardial,  exocardial, 
or  frictional  murmurs,  and  those  made  within  the  cardiac 
cavity,  endocardical  murmurs. 

Pericardial  'ynurmurs,  or  friction  sounds,  are  made  by  the  rub- 
bing upon  one  another  of  the  roughened  surfaces  of  the  pericar- 
dial membrane  during  the  early  stages  of  inflammation.  The 
sounds  have  a  rubbing,  creaking,  or  grating  character,  and  are 
differentiated  from  a  pleural  friction  sound  by  their  being  limited 
to  the  precordium,  synchronous  with  every  sound  of  the  heart, 
and  not  influenced  by  respiration.  They  are  distinguished 
from  an  endocardial  murmur  by  their  superficial  rubbing, 
creaking,  or  grating  character,  and  by  not  being  transmitted 
beyond  the  limits  of  the  heart,  either  along  the  course  of  the 
vessels,  or  to  the  left  axilla  or  back. 

Endocardinal  murmurs  are  of  two  kinds,  viz.,  organic  and 
functional. 


414  PHYSICAL   DIAGNOSIS. 

Functional  endocardial  (also  called  hemic,  or  anemic,  or 
hlood  m-urmurs)  are  the  result  of  changes  in  the  normal  con- 
stituents of  the  blood. 

Their  character  is  soft,  they  are  heard  most  distinctly  at  the 
base  of  the  left  of  the  sternum,  during  the  systole,  are  not 
transmitted  beyond  the  limits  of  the  heart,  either  to  the  left 
axilla  or  the  back,  and  they  are  associated  with  general  anemia. 

Organic  endocardial  murmurs  are  produced  by  blood  currents 
pursuing  either  a  normal  or  an  abnormal  direction. 

In  health  there  are  two  direct  hlood  currents  upon  each  side  of 
the  heart,  viz.,  the  current  from  the  left  auricle  to  the  left 
ventricle,  the  mitral  direct  current;  the  current  from  the  left 
ventricle  to  the  aorta,  the  aortic  direct  current;  the  current  from 
the  right  auricle  to  the  right  ventricle,  the  tricuspid  direct  cur- 
rent; and  the  current  from  the  right  ventricle  to  the  pulmonary 
artery,  the  pulmonic  direct  current. 

When  from  disease  the  valves  are  not  properly  closed,  the 
blood  is  allowed  to  flow  back  against  the  direct  current,  pro- 
ducing abnormal  blood  currents;  thus,  when  the  mitral  valve  is 
incompetent,  the  blood  flows  from  the  left  ventricle  back  into 
the  left  auricle  during  the  cardiac  systole,  producing  the  mitral 
regurgitant  or  indirect  current;  when  the  aortic  valves  are  in- 
competent, the  blood  is  permitted  to  flow  from  the  aorta  into 
the  left  ventricle  during  the  cardiac  diastole,  producing  the 
aortic  regurgitant  or  indirect  current;  when  the  tricuspid  valves 
are  incompetent,  the  blood  flows  from  the  right  ventricle  back 
into  the  right  auricle  during  the  systole,  producing  the  tricuspid 
regurgitant  or  indirect  current;  when  the  pulmonary  valves  are 
incompetent,  the  blood  flows  from  the  pulmonary  artery  into 
the  right  ventricle,  producing  the  pulmonic  regurgitant  or 
indirect  current. 

The  mitral  direct  current  occurs  during  the  contraction  of  the 
left  auricle,  or  just  before  the  first  sound  of  the  heart  and 
immediately  after  its  second  sound.  The  aortic  direct  current 
is  produced  by  the  contraction  of  the  left  ventricle,  and  occurs 
with  the  first  sound  of  the  heart.  The  tricuspid  direct  current 
occurs   during  the   contraction    of    the   right   auricle,    or  just 


PHYSICAL   DIAGNOSIS.  4^5 

before  the  first  or  immediately  after  the  second  sound.  The 
pulmonic  direct  current  is  produced  by  the  contraction  of  the 
right  ventricle,  occurring  during  the  first  cardiac  sound. 

The  mitral  direct  or  presystolic  murfmir  occurs  before  the  first 
sound  of  the  heart  and  immediately  after  the  second  sound.  It 
is  caused  by  a  narrowing  of  the  mitral  orifice,  has  a  blubbering 
quality,  well  imitated  by  throwing  the  lips  into  vibration  by 
the  breath,  of  a  low  pitch,  and  it  has  its  seat  of  greatest  intensity 
at  the  cardiac  apex,  and  is  not  transmitted  to  the  left  axilla  or 
to  the  base  of  the  heart. 

The  mitral  regurgitant  or  systolic  ynurmur  occurs  with  the  first 
sound  of  the  heart,  resulting  from  the  failure  of  the  mitral 
valves  to  close  the  mitral  orifice  during  the  systole,  in  conse- 
quence of  which  the  blood  flows  back,  or  regurgitates  into  the 
left  auricle.  It  is  usually  of  a  blowing  or  churning  character, 
and  has  its  seat  of  greatest  intensity  at  the  cardiac  apex,  being 
well  transmitted  to  the  left  axilla  and  inferior  angle  of  the  left 
scapula. 

The  aortic  direct  murmur  occurs  with  the  first  sound  of  the 
heart.  It  is  caused  by  a  narrowing  of  the  aortic  orifice,  has  a 
rough  or  creaking  character,  is  of  high  pitch,  having  its  seat  of 
greatest  intensity  in  the  second  intercostal  space,  to  the  right 
of  the  sternum,  and  is  well  transmitted  over  the  carotid  artery. 

The  aortic  regurgitant  murmur  occurs  with  the  second  sound 
of  the  heart,  and  is  caused  by  the  failure  of  the  aortic  valves  to 
close  the  aortic  orifice  during  the  diastole,  permitting  the  blood 
to  flow  back  or  regurgitate  into  the  left  ventricle.  It  is  usually 
of  a  blowing  or  churning  character  and  of  low  pitch,  having  its 
seat  of  greatest  intensity  over  the  base  of  the  heart,  and  is  well 
transmitted  downward  toward  or  below  the  cardiac  apex.  It 
is  the  only  organic  murmur  heard  in  the -left  side  of  the  haart 
which  occurs  with  the  second  sound  of  the  heart. 

The  tricuspid  direct  murmur  occurs  before  the  first  sound  of 
the  heart  and  immediately  after  the  second  sound.  It  is  caused 
by  a  narrowing  of  the  tricuspid  orifice,  has  a  blubbering  quality, 
and  is  low  in  pitch,  having  its  seat  of  greatest  intensity  near  the 
ensiform  cartilage.     This  murmur  is  exceedingly  rare. 


•s^ 


41 6  SYMPTOMATOLOGY. 

The  tricuspid  regurgitant  wiurmuj  occurs  with  the  first  sound 
of  the  heart,  the  result  of  the  failure  of  the  tricuspid  valves  to 
close  the  tricuspid  orifice  during  the  systole,  thus  allowing  the 
blood  to  flow  back  or  regurgitate  into  the  right  auricle.  It  is 
usually  of  a  blowing  or  soft,  churning  character,  having  its  seat 
of  greatest  intensity  at  the  ensiform  cartilage.  This  murmur  is 
also  very  infrequent,  and  occurs  mostly  when  the  right  ventricle 
is  considerably  dilated,  and  without  the  existence  of  any  valvu- 
lar tricuspid  disease. 

The  pulmonic  direct  murmur  occurs  with  the  first  sound  of 
the  heart.  It  is  generally  connected  with  congenital  lesions. 
It  occurs  at  the  same  instant  that  the  aortic  direct  murmur 
occurs,  and  is  distinguished  from  the  latter  by  its  not  being 
transmitted  into  the  carotid  artery,  whereas  the  aortic  direct 
murmur  is  always  thus  transmitted. 

The  pulmonary  regurgitant  murmur  occurs,  like  the  aortic 
regurgitant  murmur,  with  the  second  sound  of  the  heart.  This 
murmur  is  exceedingly  rare,  and  its  presence  is  only  positively 
differentiated  from  the  aortic  regurgitant  murmur  by  the  absence 
of  aortic  lesions  and  symptoms. 

SYMPTOMATOLOGY. 

The  Pulse. — The  arterial  pulsation  indicates  the  frequency, 
rhythm,  and  force  of  the  cardiac  action  and  the  blood  pressure. 
In  the  prenatal  period  the  pulse  varies  in  frequency  from  120  to 
140  beats  per  minute;  in  young  children  from  90  to  100;  in 
healthy  adults  from  72  to  80;  and  in  old  age  from  80  to  100. 
In  females  it  is  slightly  greater  in  frequency  than  in  males. 

Tachycardia  or  increased  frequency  in  the  pulse  may  be 
physiologic  or  pathologic.  It  may  be  physiologically  accele- 
rated as  the  result  of  physical  or  mental  exertion,  fear,  excite- 
ment, etc.,  after  a  heavy  meal,  or  when  the  erect  posture  is 
assumed.  It  may  be  pathologically  increased  as  the  result  of 
stimulation  by  drugs,  fevers,  heart  disease,  reflex  irritation, 
exophthalmic  goitre,  and  various  morbid  conditions  at  the  base 
of  the  brain  interfering  with  the  function  of  the  pneumogastrics. 


SYMPTOMATOLOGY.  4 1  7 

It  may  occasionally  arise  as  an  independent  affection,  no  cause 
being  demonstrable. 

Bradycardia  or  infrequency  of  the  pulse,  sloiv  pulse,  may  be 
observed  in  jaundice,  atheroma,  lesions  of  the  cerebral  centers, 
especially  such  as  irritate  the  pneumogastric  nerves  at  their 
origin,  fatty  degeneration  of  the  heart,  aortic  stenosis,  in  the 
terminal  stages  of  certain  febrile  affections,  and  after  the  inges- 
tion of  drugs  such  as  digitalis,  aconite,  and  opium.  Occasionally 
this  condition  may  be  observed  in  health  without  obvious  cause 
and  as  a  purely  physiologic  phenomenon. 

The  rhythm  of  the  pulse  is  also  subject  to  variations 
{arrhyth'^nia) . 

The  intermittent  pulse  may  be  observed  as  the  result  of 
excessive  eating,  the  habitual  use  of  tobacco,  coffee,  and  tea, 
exercise,  mental  excitement,  myocardial  disease,  and  reflex 
irritation  such  as  produced  by  constipation,  dyspepsia,  lithemia, 
hypochondriasis,  etc. 

.  The  irregular  pulse  may  be  due  to  the  same  causes  as  the 
preceding.  As  a  pathologic  condition,  it  is  most  often  encount- 
ered in  organic  cardiac  disease,  especially  that  which  gives 
rise  to  mitral  regurgitation. 

The  dicrotic  pulse  is  one  in  which  the  first  impulse  is  quickly 
followed  by  another  impulse  or  secondary  wave.  It  owes  its 
production  largely  to  conditions  which  relax  the  arterial  walls 
and  lower  the  tension,  especially  adynamic  affections  such  as 
typhoid  fever. 

Pulsiis  paradoxus  is  that  condition  of  the  pulse  in  which  the 
pulse-wave  becomes  small  and  feeble  during  inspiration;  it 
m.ay  occur  in  health  but  is  rather  common  as  the  result  of 
pericardial  adhesions. 

Water-hammer  or  Corrigans  pulse  is  that  pulse  which  is 
characterized  by  a  short,  sharp,  strong  impulse  w^hich  seems  to 
collapse  under  the  examiner's  fingers.  It  is  best  detected  by 
holding  the  arm  up,  and  is  diagnostic  of  aortic  regurgitation 
during   compensation. 

A  full  pulse  is  one  in  which  the  volume  is  large  and  is  encount- 
ered in  the  robust  and  plethoric ;  a  small  pulse  has  a  weak  beat 
27 


41 8  SYMPTOMATOLOGY. 

and  small  volume,  and  is  observed  in  exhausting  or  debilitating 
conditions,  aortic  stenosis,  mitral  stenosis,  myocarditis,  Bright's 
disease,  acute  peritonitis,  and  during  a  chill. 

A  strong  pulse  has  a  strong  impulse  and  very  little  compressi- 
bility, and  is  found  in  robust  individuals  and  in  cardiac  hyper- 
trophy; a  weak  pulse  is  the  direct  opposite  and  attends  asthenic 
affections. 

Tension  of  the  ptilse  expresses  the  degree  of  distention  of  the 
arteries,  or  blood  pressure.  The  pulse  may  be  hard  or  soft.  A 
hard  pulse  is  one  of  high  tension  or  in  which  the  contractile 
power  of  the  arterial  walls  is  great.  The  artery  consequently 
remains  continuously  full  between  the  beats.  Among  its 
causes  may  be  mentioned  plethora,  increased  cardiac  action 
with  contraction  of  the  arterioles,  capillary  obstruction  from 
various  causes,  cardiac  hypertrophy,  arteriosclerosis,  inter- 
stitial nephritis,  gout,  lithemia,  uremia,  lead-poisoning,  preg- 
nancy, anemia,  apoplexy,  brain  tumor,  etc.  A  soft  pulse  is 
one  of  low  tension  and  easily  compressible,  due  directly  to  a 
lowered  tone  of  the  vessel  walls.  This  may  occur  physiologi- 
cally. As  an  abnormal  condition  it  is  encountered  in  asthenic 
affections  such  as  typhoid  fever,  cardiac  degeneration, 
collapse,  etc.  It  may  occur  in  obese  individuals  and  after 
diarrhea,  warm  baths,  hot  applications,  hot  drinks,  and  copious 
urination. 

Palpitation  of  the  heart  consists  of  abnormal  rapidity  with 
fluttering  and  tremor  of  the  organ,  of  which  the  patient  is 
conscious.  It  is  usually  purely  functional  in  origin  and  may  be 
traced  in  most  cases  to  gastrointestinal  disturbances,  excite- 
ment, hysteria,  overwork,  etc.  It  may  be  also  due  to  organic 
heart  disease,   exophthalmic  goitre,   and  anemia. 

Dropsy. — Serous  infiltration  of  the  cellular  tissues  and  cavities 
of  the  body  frequently  is  indicative  of  heart  disease,  especially 
when  it  is  bilateral.  When  localized  to  certain  regions  as  the 
ankles  it  is  termed  edema,  and  when  generalized  it  is  known  as 
anasarca. 

Cyanosis  is  the  term  applied  to  blueness  of  the  body  surface 
and  is  due  to  deficient  oxidation  of  the  blood  as  the  result  of 


ACUTE    PERICARDITIS.  4J9 

local  or  general  circulatory  disturbances.  It  therefore  accom- 
panies various  forms  of  chronic  heart  disease.  It  may  be 
congenital  as  the  result  of  cardiac  malformations. 

Pain  in  the  precordial  region  may  be  due  to  disease  of  the 
heart  or  pericardium,  neuralgia,  pleurodynia,  myalgia,  localized 
pleurisy,  periostitis,  or  abscess.  Cardiac  disease  may  induce 
acute,  excruciating  pain  in  the  epigastrium.  Disturbances  of 
rhythm,  valvular  disease,  and  angina  pectoris  are  common 
causes  of  cardiac  pain.  Pericarditis  is  attended  by  paroxysmal 
pain  over  the  heart  which  may  radiate  to  the  left  shoulder 
and  down  the  arm,  being  increased  by  pressure,  movement,  and 
respiration.  Inflammation,  atheroma,  or  aneurysm  of  the 
aorta  may  be  the  cause  of  pain  in  the  precordial  region. 

Dyspnea  is  also  a  symptom  of  heart  disease  and  may  be  due 
to  exertion,  or  it  may  occur  paroxysmally.  Orthopnea  is 
observed  in  grave  cases,  as  is  also  rhythmic  dyspnea  or  Cheyne- 
Stokes  breathing. 

.  Cerbral  symptoms  may  be  induced  by  cardiac  disease. 
Among  these  may  be  mentioned  vertigo,  faintness,  dullness, 
languor,  stupor,  moderate  delirium,  coma,  chorea,  epileptiform 
convulsions,  etc. 

Gastrointestinal  symptoms  such  as  dyspepsia,  flatulence, 
nausea,  vomiting,  a,nd  similar  manifestatons  of  gastric  conges- 
tion may  attend  organic  heart  disease. 


DISEASES  OF  THE  PERICARDIUM. 
ACUTE  PERICARDITIS. 

Definition. — An  acute  fibrinous  inflammation  of  the  pericar- 
dium; characterized  by  slight  fever,  pain,  precordial  distress, 
and  disturbed  cardiac  action  and  circulation.  If  the  inflamma- 
tion be  limited  to  the  parietal  or  visceral  layer,  or  to  a  part  of 
either,  it  is  termed  partial  or  circumscribed  pericarditis;  if  it 
involve  the  whole  of  both  surfaces,  it  is  termed  general  or 
diffused  pericarditis.  The  inflammation  may  be  primary  or 
secondary. 


420  ACUTE    PERICARDITIS. 

Causes. — Primary  pericarditis  resulting  directly  from  cold 
and  exposure  or  injuries  is  rare.  Secondary  pericarditis  follows, 
or  is  associated  with,  rheumatism,  influenza,  scarlatina,  variola, 
puerperal  fever,  tuberculosis,  septicemia,  Bright's  disease,  gout, 
scurvy,  diabetes.,  and  with  pneumonia  and  pleuropneumonia, 
particularly  in  alcoholics.      Bacterial  infection  is  the  direct  cause. 

Pathologic  Anatomy. — The  structural  changes  in  this  affec- 
tion are  similar  to  inflammation  in  other  serous  membranes. 
These  changes  present  themselves  as  acute  plastic  or  dry  peri- 
carditis, or  pericarditis  with  a  serofibrinous,  hemorrhagic,  or 
purulent  effusion.  The  earliest  change  is  that  of  hyperemia, 
most  marked  on  the  visceral  layer,  giving  it  a  dull  red  appear- 
ance, which  is  followed  by  the  exudation  of  lymph  in  scattered 
and  irregular  patches  causing  the  membrane  to  appear  rough 
and  shaggy  (dry  pericarditis).  Later,  there  is  an  effusion 
poured  out  which  may  be  serofibrinous,  hemorrhagic,  or  puru- 
lent. In  serofibrinous  pericarditis  the  effused  material  con- 
sists largely  of  straw-colored  fluid  which  varies  in  quantity 
from  a  few  ounces  to  i  or  2  pints  or  more.  The  extravasation 
of  blood  into  the  sac  from  any  cause  during  the  affection  gives 
rise  to  the  hemorrhagic  form,  and  the  purulent  variety  results 
from  pyogenic  infection  of  the  membrane.  When  the  serum 
is  deficient  in  the  exudate  and  fibrin  predominates,  the  effusion 
is  extremely  scant  and  the  term  fibrinous  pericarditis  is  applied. 
Its  onset  is  less  acute  and  the  tendency  to  form  adhesions  is  very 
great.  Varying  grades  of  myocardial  inflammation  are  en- 
countered in  combination  with  pericarditis. 

Symptoms. — Acute  pericarditis  may  be  well  marked  and  still 
present  none  of  the  characteristic  subjective  symptoms.  It  usu- 
ally begins  with  rigors,  fever  of  the  remittent  type,  frequently 
nausea  and  vomiting,  precordial  distress  and  tenderness,  acute 
shooting  pains,  increased  by  breathing  and  coughing;  dry,  sup- 
pressed cough;  increased  cardiac  action,  and  sometimes  violent 
palpitation.  An  attack  of  pericarditis  secondary  to  an  existing 
disease  presents  no  marked  symptoms  other  than  those  men- 
tioned to  indicate  its  onset.  Attacks  of  nausea  and  vomiting 
occurring  during  the  course  of  rheumatism,  pneumonia,  pleurisy, 


ACUTE    PERICARDITIS.  42  I 

and  nephritis  should  always  call  attention  to  the  heart.  The 
duration  of  this  early  stage  is  from  a  few  hours  to  a  day  or  two. 

During  the  stage  of  effusion,  the  symptoms  vary  with  the 
amount  of  effusion  and  the  rapidity  with  which  it  is  formed. 
There  are  precordial  oppression,  tendency  to  syncope,  dyspnea 
at  times  amounting  to  orthopnea,  dysphagia,  hiccough,  nausea, 
vomiting,  feeble  irregular  pulse,  and  sometimes  melancholia, 
delirum,    or   acute    maniacal   excitement. 

Absorption  is  usually  rapid,  but  the  heart  remains  irritable 
for  quite  a  long  period.  If  absorption  does  not  occur  and  the 
fluid  accumulates  continuously  without  destroying  life  at  the 
time,  the  pericardial  sac  becomes  dilated,  and  chronic  pericar- 
ditis is  produced. 

A  purulent  effusion  in  the  pericardial  sac  is  evidenced  by 
irregular  fever,  chills,  sweats,  and  leukocytosis  in  addition  to 
the  symptoms  already  given. 

Physical  Signs. — Inspection  during  the  early  stage  shows 
excited  cardiac  action  as  evidenced  by  the  impulse.  During 
the  effusion  stage,  the  impulse  is  feeble,  undulatory,  or  absent; 
it  is  usually  displaced  upward,  very  rarely  downward,  the 
precordium  bulges,  and  the  abdomen  protrudes  when  the  effusion 
is  large. 

Palpation  during  the  early  stage  serves  to  detect  an  excited 
or  tumultuous  impulse,  and  in  very  rare  instances  pericardial 
friction  fremitus.  During  the  effusion  stage,  the  impulse  is 
feeble  or  absent  and  when  present  is  considerabl}^  displaced. 
Tenderness  may  be  elicited. 

Percussion  is  normal  in  the  beginning  of  the  disease  but  as 
the  effusion  forms  the  cardiac  dullness  becomes  enlarged  verti- 
cally and  laterally.  If  the  accumulation  of  fluid  is  considerable, 
the  dullness  assumes  a  triangular  shape  with  the  base  on  a  line 
with  the.  sixth  or  seventh  rib  extending  from  the  right  of  the 
sternum  to  the  left  of  the  left  nipple  and  the  apex  at  the  sternal 
attachment  of  the  second  rib  or  higher.  The  shape  of  the  dull- 
ness is  sometimes  altered  by  changing  the  position  of  the  patient. 

Ausculation  at  the  onset  reveals  excited  cardiac  action  and 
usually  an  exocardial  murmur  or  friction  sound,  synchronous 


42  2  ACUTE   PERICARDITIS. 

with  the  cardiac  sounds  and  nninfliienced  by  respiration  but 
often  increased  by  pressure  with  the  stethoscope.  Later  as  the 
effusion  forms,  the  cardiac  sounds  are  feeble  and  deep-seated 
at  the  apex,  becoming  louder  and  distinct  toward  the  cardiac 
base.  The  friction  sound  is  sometimes  heard  at  the  base.  As 
absorption  progresses,  the  friction  sound  returns,  being  replaced 
shortly  by  the  normal  heart  sounds. 

Diagnosis. — Acute  endocarditis  may  be  distinguished  from 
acute  pericarditis  by  the  absence  of  friction  sound  and  triangular 
dullness  and  by  the  presence  of  soft  systolic  or  diastolic  mur- 
murs heard  best  over  one  of  the  valve  points. 

Cardiac  hypertrophy  is  unattended  by  acute  symptoms, 
friction  sound,  or  evidences  of  effusion.  The  onset  is  less  sudden. 
The  impulse  is  strong  and  the  sounds  are  loud. 

Cardiac  dilatation  is  characterized  by  enlargement  of  the  area 
of  dullness  downward,  undulatory  impulse,  and  clear  and  dis- 
tinct heart  sounds.     There  is  no  friction  sound. 

Hydropericardium  is  attended  by  the  physical  signs  common 
to  pericardial  effusion,  but  at  no  time  is  a  friction  sound  obtained 
on  examination.  The  history  of  other  dropsies  and  their 
underlying  diseases  aids  in  making  the  diagnosis. 

Prognosis. — This  is  controlled  by  the  severity  of  the  inflam- 
mation, its  causes,  and  the  coexisting  conditions.  Pericarditis 
with  slight  effusion  is  frequently  overlooked  and  often  termi- 
nates favorably  without  being  detected.  Simple  serofibrinous 
pericarditis  without  complications  and  under  proper  treat- 
ment ends  in  recovery  in  from  one  to  three  weeks.  In  debili- 
tated subjects  the  disease  is  prolonged.  The  rapid  effusion  of 
large  quantities  of  fluid  may  cause  sudden  death.  Purulent 
effusions  are  usually  fatal.  Fibrinous  pericarditis  is  attended 
by  adhesions  and  subsequent  changes  in  the  heart  muscle. 
Relapses  are  not  infrequent. 

Treatment. — Absolute  rest  in  bed  with  mental  quiet  is 
necessary.  Death  has  followed  neglect  of  this  simple  precaution. 
Milk  diet  should  be  prescribed.  Local  applications  are  espe- 
cially valuable  in  the  early  stage :  in  vigorous  patients  leeches  or 
wet  cups  applied  to  the  precordium  followed  by  ice-poultices 


ACUTE    PERICARDITIS.  423 

or  iced  compresses;  in  the  feeble  and  debilitated,  dry  cups  to 
the  precordium,  followed  by  poultices.  Blisters  are  also  very 
beneficial.  Cold  applications  by  means  of  Leiter's  coil  or  ice- 
bags  are  sometimes  more  comfortable  than  the  foregoing  proce- 
dures. Occasionally  heat  is  more  serviceable.  The  hypodermic 
injection  of  morphin  sulphate,  gr.  1/4  (0.0165  gm.),  and  atropin 
sulphate,  gr.  1/150  (0.00044  gm.),  serves  to  relieve  pain  and 
quiet  the  heart. 

•  Mercury  is  often  of  value  in  relieving  the  gastrointestinal 
symptoms  and  in  lessening  the  pericardial  inflammation.  The 
following  formula  is  employed  with  benefit: 

I^.      Hydrargyri  chloridi  mitis   gr.  1/3  .022  gm. 

Sodii  bicarbonat gr-  ij  -13     gm. 

Sacchar.  lactis gr-  ij  .13     g"^- 

M.   S. — To  be  taken  dry  on  the  tongue  every  two  hours 
until  free  action  of  the  bowels  is  obtained. 

The  late  Dr.  Pepper  recommended  the  following  combination : 

I^.      Pulv.  digitalis 

Mass.  hydrargyri aa  gr.  x  aa  .  6  gm. 

Pulv.  opii gr-  V  .3  gm. 

Quininae  sulph gr.  xxx  2  .     gm. 

M.     Ft.  mass  et  div.  in  pil.  No.  xx. 
S. — One  pill  three  or  four  times  daily. 

In  young,  vigorous  patients,  the  excited  cardiac  action  may 
be  controlled  early  in  the  disease  by  small  doses  of  aconite  or 
veratrum  viride;  in  adults,  the  aged,  and  feeble  individuals, 
digitalis,  in  doses  sufficient  to  steady  the  heart,  but  not  to 
stimulate  too  forcibly,  should  be  employed.  Quinin,  strychnin, 
alcohol,  and  ammonia  are  of  value  in  all  cases.  In  secondary 
cases,  except  those  due  to  rheumatism,  cardiac  sedatives  should 
be  avoided;  the  treatment  recommended  for  the  primary  con- 
dition should  be  continued  and  combined  with  the  measures 
indicated  for  the  pericarditis. 

During  the  stage  of  effusion,  the  diet  should  still  be  liquid, 
and  stimulants  should  be  continued  to  maintain  the  heart's 


424  CHRONIC    PERICARDITIS. 

action.  Ammonium  carbonate,  solution  of  ammonium  acetate, 
potassium  acetate,  potassium  carbonate,  quinin  sulphate,  and 
saline  purgatives  are  also  indicated  Diuretics  may  be  employed 
but  diaphoretics  such  as  pilocarpin  are  contraindicated.  If  the 
effusion  gives  rise  to  marked  pressure  symptoms,  tapping  should 
be  performed  either  in  the  fossa  between  the  ensiform  and 
costal  cartilages  on  the  left  side,  or  in  the  fifth  left  interspace 
near  the  junction  of  the  sixth  rib  with  its  cartilage.  Blisters 
and  potassium  iodid  aid  in  absorption  of  the  exudate. 

When  the  exudate  is  purulent,  incision  of  the  ch^st  wall  and 
drainage  of  the  pericardial  sac  is  indicated.  The  toxemia  is 
profound  and  tonics  and  stimulants  should  be  given  very  freely. 

CHRONIC  PERICARDITIS. 

Synonym. — Adhesive  pericarditis. 

Definition. — A  chronic  inflammation  of  the  pericardium, 
with  either  distention  of  the  sac  by  fluid,  or  adhesions  of  the 
pericardium  (adherent  pericardium);  characterized  by  impaired 
cardiac  action  and  disturbances  of  the  circulation. 

Cause. — The  affection  is  always  secondary  to  an  acute  attack. 

Pathologic  Anatomy. — If  the  fluid  is  absorbed,  the  pericar- 
dial surfaces__  become  agglutinated  by  several  layers  of  lymph, 
which  serve  to  increase  the  "  thickness  of  the  sac  wall  1/2 
inch  or  more.  Often  the  outer  surface  of  the  pericardium  be- 
comes adherent  to  the  chest  walls.  If  the  fluid  is  not  absorbed, 
it  may  continue  to  accumulate,  distending  the  sac  in  all  direc- 
tions, displacing  the  diaphragm,  and  interfering  with  the  func- 
tions of  adjacent  viscera;  or  a  low  grade  of  septic  inflammation 
may  supervene  with  the  formation  of  a  purulent  effusion  {em- 
pyema of  the  pericardium),  the  disease  terminating  fatally  after 
a  varying  period. 

Symptoms. — Precordial  pain  and  distress  are  prominent 
symptoms.  Cardiac  action  is  irregular  and  feeble,  and  dyspnea, 
worse  on  movement,  with  other  signs  of  embarrassed  circula- 
tion is  present.  When  agglutination  of  the  walls  occurs, 
there  arises  a  great  tendency  to  pulmonary  inflammation. 


HYDROPERICARDIUM.  425 

Physical  Signs. — Inspection  detects  bulging  of  the  precordium 
and  displacement  of  the  impulse  if  the  effusion  is  yet  present. 
If  the  pericardium  is  adherent  to  the  chest  wall,  depression  of 
the  precordium  and  recession  of  the  intercostal  spaces  {systolic 
dimpling)  and  epigastrium  with  every  systole,  will  occur. 
The  interspaces  are  narrowed  and  the  impulse  is  more  diffuse 
but  displaced  and  uninfluenced  by  deep  inspiration. 

Palpation  serves  to  confirm  inspection.  In  the  presence  of  an 
effusion,  the  impulse  is  displaced  and  feeble  or  absent;  if  ad- 
hesions exist,  the  impulse  is  displaced  and  tumultuous.  A 
friction  fremitus  may  occasionally  be  obtained. 

Percussion  will  be  of  service  in  outlining  dullness  correspond- 
ing to  the  effusion,  if  any  is  present.  If  adhesions  only  exist, 
the  cardiac  dullness  is  but  slightly  modified. 

Auscultation  reveals  feeble  and  deep-seated  cardiac  sounds 
at  the  apex,  and  loud  and  more  distinct  sounds  at  the  base  if 
there  is  any  effusion.  If  adhesions  are  present  the  cardiac 
sounds  are  unaltered  and  a  rough  friction  sound  or  exocardial 
murmur  may  be  obtained. 

Treatment. — The  cardiac  action  should  be  carefully  watched' 
and  maintained  by  stimulants,  as  advised  in  the  acute  form. 
Blisters,  potassium  iodid,  purgation,  and  other  means  calcu- 
lated to  absorb  inflammatory  exudates  should  be  employed. 
Paracentesis  may  be  necessary.  Incision  is  indicated  if  the 
effusion  becomes  purulent. 

HYDROPERICARDIUM. 

Synonym. — Pericardial  dropsy. 

Definition. — The  accumulation  of  fluid  in  the  pericardial  sac 
without  inflammation,  characterized  by  precordial  distress,  dis- 
turbed cardiac  action,  dyspnea,  and  dysphagia. 

Causes. — It  is  always  a  secondary  affection  being  due  to 
heart  disease,  Bright's  disease,  pneumothorax,  pressure  of  an 
aneurysm  or  other  mediastinal  tumor,  or  disease  of  the  car- 
diac veins. 

Pathology. — A  pericardial  effusion  is  formed  without  any  evi- 


426  ACUTE   ENDOCARDITIS. 

dences  of  inflammatory  changes.  The  fluid  may  range  in  quan- 
tity from  an  ounce  to  i  or  2  pints  and  is  usually  clear,  yellowish, 
and  straw-colored  and  of  an  alkaline  reaction. 

Symptoms. — Manifestations  of  dropsy  in  other  parts  of  the 
body,  or  anasarca,  are  present.  The  pericardial  involvement 
is  indicated  by  disturbances  of  the  heart's  action,  dyspnea, 
dysphagia,  dry  cough,  and  other  manifestations  of  cardiac 
embarrassment . 

Physical  signs  are  those  of  pericardial  effusion  from  other 
causes;  the  friction  sound,  however,  is  never  obtained. 

Diagnosis. — A  differentiation  between  this  affection  and  peri- 
carditis with  effusion  can  be  made  only  by  consideration  of  the 
history  and  the  results  of  aspiration. 

Prognosis. — The  outlook  depends  entirely  upon  the  nature  of 
the  underlying  disease. 

Treatment. — The  effusion  calls  for  paracentesis  if  the  cardiac 
action  is  seriously  disturbed.  The  major  portion  of  the  treat- 
ment should  be  directed  toward  the  original  cause  of  the  dropsy. 

DISEASES  OF  THE  ENDOCARDIUM. 

ACUTE  ENDOCARDITIS. 

Synonyms. — Valvulitis;  exudative  endocarditis. 

Definition. — An  acute  fibrinous  inflammation  of  the  serous 
membrane  lining  the  cavity  of  the  heart  and  particularly  its 
valves,  in  severe  cases  the  chordae  tendinae  being  involved, 
resulting  in  changes  in  the  valves  or  orifices  of  the  heart,  or 
both;  characterized  by  cough,  dyspnea,  disturbed  cardiac 
action,  nausea,  vomiting,  and  more  or  less  marked  febrile  re- 
action. Acute  endocarditis  occurs  in  two  distinct  forms: 
plastic  or  simple  exudative  endocarditis ;  ulcerative  or  diptheritic 
endocarditis.  The  ulcerative  form  is  considered  under  a  sepa- 
rate heading  (see  Malignant  Endocarditis). 

Causes. — Acute  simple  endocarditis  is  usually  secondary  to 
some  other  affection,  particularly  acute  articular  rheumatism 
(especially    in    young    people),    chorea,    pleurisy,    pneumonia, 


ACUTE    ENDOCARDITIS.  42? 

pericarditis,  Bright's  disease,  and  the  infectious  fevers  such  as 
scarlatina,  influenza,  and  diphtheria.  Gonorrhea  is  an  occa- 
sional cause.  Cachectic  states  such  as  accompany  tuberculosis 
and  cancer  are  predisposing  causes.  It  may  be  secondary  to 
chronic  endocarditis. 

Pathology. — Acute  simple  endocarditis  may  be  prenatal  as 
well  as  postnatal.  In  the  former  class  of  cases,  the  right  side  of 
the  heart  is  usually  involved,  while  in  those  instances  observed 
after  birth,  the  disease  is  most  often  limited  to  the  left  side. 
While  the  disease  may  attack  the  entire  lining  membrane  of  the 
heart  it  is  especially  marked  at  the  valvular  portions  of  the 
endocardium.  The  earliest  change  is  that  of  hyperemia  of  the 
membrane  rendering  it  red  and  swollen.  As  the  inflammatory 
exudate  is  thrown  out  the  surface  of  the  valves  become  rough- 
ened and  warty  excrescences  are  formed.  These  verrucose 
formations  are  to  be  found  on  the  auricular  surface  of  the 
mitral  valve  and  on  the  ventricular  surface  of  the  aortic  valve 
at  the  line  of  contact  of  their  leaflets,  usually  from  i  to  2  mm. 
from  their  free  margin.  These  vegetations  are  produced  by  a 
proliferation  of  the  cells  of  the  adventitia  and  of  the  external 
connective  tissue ;  fibrin  from  the  blood  is  deposited  on  the 
formations,  thus  serving  to  increase  their  size.  The  excres- 
cences are  friable  and  may  be  easily  detached  or  broken  off 
and  carried  in  the  blood  stream  as  emboli,  to  various  parts  of 
the  body,  particularly  the  left  side  of  the  brain,  the  kidneys, 
and  the  spleen.  If  retained  in  position,  fibrous  tissue  is  eventu- 
ally formed;  the  valves  become  thickened  and  contracted 
producing  chronic  endocarditis.  The  leaflets  may  then  become 
the  seats  of  various  infiltrations. 

Symptoms. — Occurring,  as  it  does,  in  the  course  of  some  other 
disease  the  subjective  symptoms  of  acute  simple  endocarditis 
are  usually  masked  by  the  manifestations  of  the  primary  condi- 
tion, until  disturbances  of  the  circulation  direct  attention  to  the 
heart.  Increase  of  temperature,  precordial  distress,  cough, 
slight  dyspnea,  and  more  or  less  persistent  vomiting  may  be 
present.  The  action  of  the  heart  is  increased  and  often  tumul- 
tuous.    The  carotids  throb  and  there  are  noises  in  the  ear.     As 


428  .         ACUTE    ENDOCARDITIS. 

the  infiamination  progresses,  the  cardiac  action  and  pulse  be- 
come less  frequent,  and  venous  stasis  and  more  or  less  pulmonary 
congestion  occur.      The  attack  lasts  from  one  to  three  weeks. 

Physical  Signs. — Auscultation  reveals  a  change  in  the  char- 
acter of  the  sounds  (prolongation)  and  sometimes  the  develop- 
ment of  a  murmur  corresponding  to  the  affected  valve. 

Diagnosis. — In  all  diseases  in  which  endocarditis  is  liable  to 
occur,  physical  examination  of  the  chest  should  be  made  at  fre- 
quent intervals  as  the  symptoms  are  by  no  means  distinctive  and 
the  diagnosis  is  made  largely  by  the  physical  signs. 

Pericarditis  is  distinguished  from  endocarditis  by  the  character 
of  the  physical  signs.  In  pericarditis,  the  murmur  or  friction 
sound  is  heard  with  either  cardiac  sound,  is  near  to  the  ear,  and 
is  influenced  by  pressure  of  the  stethoscope,  besides  being  asso- 
ciated with  more  or  less  alteration  in  the  size  and  shape  of  the 
cardiac  dullness,  and  is  not  transmitted,  while  in  endocarditis 
the  murmur  takes  the  place  of,  or  is  associated  with,  the  cardiac 
sounds,  and  is  transmitted  to  points  beyond  the  precordium, 
with  absence  or  change  in  size  and  form  of  the  cardiac  dullness 
on  percussion. 

EmhoUsm  in  the  course  of  endocarditis  produces  an  additional 
group  of  symptoms,  the  presence  of  which  may  give  rise  to  con- 
fusion. Embolism  of  the  kidneys  causes  sudden,  deep-seated 
lumbar  pain,  with  albuminuria  and  even  hematuria;  embolism 
of  the  brain,  sudden  palsies  and  sudden  disturbance  of  conscious- 
ness; of  the  spleen,  sharp  pain  and  tenderness  in  the  splenic 
region;  of  the  skin,  petechial  or  purpuric  spots. 

Prognosis. — Acute  simple  endocarditis  without  complications 
is  not  dangerous  to  life,  but  the  affected  valve  usually  remains 
damaged  and  later  becomes  the  seat  of  chronic  endocarditis. 

Treatment. — Absolute  rest  in  bed  and  liquid  diet  are  essential. 
Leeches,  wet  cups,  ice,  or  poultices  applied  to  the  precordium 
may  be  of  value.  If  the  heart  is  weak  and  irregular,  digitalis  in 
moderate  doses  may  be  employed.  Purgation  by  salines  should 
be  obtained  early  in  the  disease.  The  free  administration  of 
alkalies  such  as  ammonium  carbonate,  potassium  carbonate, 
and  potassium    acetate  until  the  urine  is  alkaline,  may  serve 


MALIGNANT    ENDOCARDITIS.  429 

to  prevent  permanent  changes  in  the  valves.  If  the  alkalies 
fail  and  the  inflammation  show  a  tendency  to  linger,  mercury- 
should  be  administered.  Dyspnea  may  usually  be  relieved  by 
the  administration  of  opium  or  morphin.  If  symptoms  of  em- 
barrassment of  the  circulation  appear  such  as  marked  dyspnea, 
cyanosis,  and  edema,  strychnin,  atropin.  nitroglycerin,  digitalis, 
ammonium  carbonate,  and  similar  heart  tonics  are  indicated. 
After  acute  symptoms  have  subsided  absorption  of  the  exudate 
may  be  brought  about  to  some  extent  by  the  free  use  of  potas- 
sium iodid. 

MALIGNANT  ENDOCARDITIS. 

Synonyms. — Ulcerative  endocarditis;  septic,  mycotic,  and 
diphtheritic  endocarditis. 

Definition. — An  acute  septic  inflammation  of  the  lining  "mem- 
brane of  the  heart,  with  a  strong  tendency  to  ulceration;  char- 
acterized by  depression  of  the  vital  forces  with  more  or  less 
cardiac  distress. 

Causes. — Microorganismal  infection  is  the  primary  cause,  but 
as  yet  a  specific  organism  has  not  been  isolated.  It  may  follow 
pneumonia,  erysipelas,  septicemia,  puerperal  fever,  influenza, 
meningitis,  gonorrhea,  or  acute  rheumatism. 

Pathologic  Anatomy. — The  changes  are  those  of  acute  en- 
docarditis up  to  the  development  of  the  thickening  of  the  endo- 
cardium lining  the  valves,  and  the  development  of  the  vegeta- 
tions. Instead  of  the  poison  spending  its  force  and  the  chronic 
condition  obtaining,  a  process  of  softening,  ulceration,  develop- 
ment of  abcesses,  and  perforation  of  leaflets  follows,  resulting  in 
loss  of  structure,  general  septic  infection,  and  the  development 
of  emboli,  which  lead  to  infarctions  in  the  brain,  kidney,  spleen, 
eye  or  skin. 

Symptoms. —  The  septic  intoxication  is  manifested  by  head- 
ache, restlessness,  delirium  of  varying  degrees,  dry  coated  tongue, 
sordes  on  the  lips  and  on  the  gums,  nausea,  vomiting,  constipa- 
tion or  diarrhea,  leukocytosis,  irregular  fever,  rigors,  and  sweats. 
The  heart's  action  is  rapid,  irregular,  and  weak,  and  the  pulse  is 
compressible.     The  spleen  is  enlarged  and  albuminuria  is  pres- 


43 O  CHRONIC   ENDOCARDITIS. 

ent.  Paroxysmal  dyspnea  and  cyanosis  are  common  symptoms. 
The  patient  frequently  experiences  a  sense  of  impending  danger, 
great  anxiety,  and  terror.  The  occurrence  of  embolism  is  marked 
by  additional  symptoms  referable  to  the  organ  affected.  If  the 
brain,  rapidly  developing  palsies  with  disorder  of  conscious- 
ness ;  if  the  kidneys,  deep-seated  lumbar  pains  with  hematuria 
or  disordered  urinary  flow;  if  the  spleen,  pain  and  tenderness 
of  the  splenic  region  with  increase  of  temperature  record. 

Physical  Signs. — Auscultation  reveals  the  replacement  of  the 
normal,  booming,  muscular,  first  sound  by  a  feeble,  irregular 
cardiac  pulsation.  Generally  a  murmur  may  be  detected  but  it 
is  subject  to  great  variations,  and  may  be  absent. 

Diagnosis. — This  is  extremely  difficult ;  the  occurrence  of  sep- 
tic phenomena  together  with  symptoms  of  cardiac  embarrass- 
ment in  the  course  of  various  affections  mentioned  under  causes, 
is  highly  suggestive. 

Typhoid  fever  is  less  acute;  the  fever  is  more  regular;  the  ab- 
dominal symptoms  are  more  marked ;  a  roseolar  eruption  is  pres- 
ent, the  leukocytes  are  not  increased;  the  Widal  reaction  is 
obtained;  and  typhoid  bacilli  are  found  in  the  stools. 

Prognosis. — The  termination  is  almost  invariably  fatal  in  from 
one  to  eight  weeks  or  more. 

Treatment. — This  is  very  unsatisfactory.  Nutritious  food 
and  stimulants  such  as  quinin,  iron,  alcohol,  strychnin,  digitalis, 
and  nitroglycerin  should  be  freely  used  to  support  the  patient 
and  to  maintain  the  heart's  action.  Sponging  will  serve  to  re- 
duce the  temperature  and  render  the  patient  more  comfortable. 
Belladonna  plaster  over  the  precordium  is  beneficial  but  other 
applications  seem  only  to  increase  the  distress.  Antistrepto- 
coccus  serum  (20  c.c.  injected  daily)  has  been  employed  by 
some  observers  with  success  and  considering  the  prognosis  of  this 
affection,  it  is  worthy  of  a  fair  trial. 

CHRONIC  ENDOCARDITIS. 

Synonym. — Chronic  valvular  disease. 

Definition. — Alterations  in  the  cardiac  valves  or  orifices, 
rendering  the  former  incapable  of  properly  closing  the  orifices 


MITRAL   REGURGITATION.  43 1 

(regurgitation),  or  causing  the  narrowed  orifice  to  interrupt  the 
blood  current  in  its  normal  movement  (stenosis). 

Varieties. — I.  Mitral  regurgitation.  II.  Aortic  regurgitation. 
III.  Tricuspid  regurgitation.  IV.  Pulmonary  regurgitation. 
V.  Mitral  obstruction.  VI.  Aortic  obstruction.  VII.  Tricuspid 
obstruction.     VIII.  Pulmonary  obstruction. 

Causes. — The  great  majority  of  cases  are  the  result  of  an  at- 
tack of  acute  endocarditis  following  rheumatism,  chorea,  or  the 
infectious  diseases.  A  chronic  endocarditis  from  the  onset 
may  be  caused  by  alcoholism,  syphilis,  gout,  or  excessive 
muscular  labor.  Chronic  Bright's  disease  is  also  an  exciting 
cause.  In  elderly  people,  chronic  endocarditis  may  often  be 
due  to  atheromatous  or  fibroid  changes. 

Compensation. — The  alteration  in  the  systemic  blood  supply 
caused  by  the  valvular  defects  of  chronic  endocardial  inflamma- 
tion are  such  that,  if  continued,  the  integrity  of  the  body  is 
threatened.  To  overcome  the  impaired  functions  of  the  valves 
and  to  maintain  the  general  circulation,  the  heart  increases  in 
size  and  strength  {compensatory  hypertrophy).  The  period  in 
which  this  occurs  is  called  the  period  of  compensation;  its  dura- 
tion is  indefinite.  It  may  be  recognized  by  the  physical  signs 
of  valvular  disease  without  any  symptoms  of  disturbed  circula- 
tion. Anything  which  disturbs  the  equilibrium  as  it  now 
exists,  such  as  acute  diseases  and  excessive  work,  leads  to 
ruptured  compensation,  a  condition  attended  by  cyanosis, 
dyspnea,  edema,  gastric,  hepatic,  and  renal  disturbances,  and 
often  death.  The  object  in  the  treatment  of  all  forms  of  chronic 
valvulitis  is  to  obtain  compensation  and  to  prevent  its  failure 
or  rupture. 

MITRAL  REGURGITATION. 

This  form  of  valvular  disease  is  also  termed  mitral  insuffi- 
ciency, and  is  the  most  frequent  variety  of  valvular  heart 
disease. 

Pathologic  Anatomy. — The  most  common  conditions  observed 
are  more  or  less  contraction  and  narrowing  of  the  tongues  of 


432  MITRAL    REGURGITATION. 

the  valves,  with  irregular  thickening  and  rigidity;  atheroma  or 
calcification  of  the  segments;  laceration  of  one  or  more  seg- 
ments; adhesion  of  one  or  more  segments  to  the  inner  surface 
of  the  ventricle;  thickened  and  stiffened,  or  ruptured,  chordcs 
tendinecE,  and  also  contraction  and  hardening  of  the  musculi 
papillares. 

As  a  result  of  the  regurgitation  or  leakage  of  the  blood  back 
into  the  left  auricle,  there  is  a  dilatation  of  the  auricle,  followed 
by  slight  cardiac  hypertrophy.  Ventricular  hypertrophy 
occurs  after  a  time  from  the  increased  number  of  the  cardiac 
contractions.  If,  as  is  eventually  the  case,  the  left  auricle  is 
unable  to  overcome  the  backward  flow  of  blood,  it  dilates  and 
the  lungs  become  congested.  The  right  ventricle  is  then  forced 
to  perform  more  work  and  hypertrophies.  Hypertrophy  of 
the  right  ventricle  is  followed  by  that  of  the  left  ventricle.  In 
the  event  of  its  failure  to  overcome  the  backward  flow,  it  (right 
ventricle)  also-  dilates  and  the  tricuspid  valve  becomes  insuffi- 
cient (see  Figs.  47  and  48). 

Symptoms. — Insufficiency  of  the  mitral  valves  soon  leads  to 
cardiac  hypertrophy,  in  order  to  compensate  for  the  diminished 
amount  of  blood  sent  onward  by  the  ventricular  systole.  This 
condition  causes  quickened  and  strong  pulse  with  some  short- 
ness of  breath  on  severe  exertion.  When  compensation  rup- 
tures, it  is  manifested  by  precordial  distress,  cough,  dyspnea, 
feeble,  soft,  rapid,  irregular  pulse,  pulmonary  congestion, 
edema  of  the  limbs,  ascites,  general  cyanosis,  hepatic  congestion, 
and  scanty  and  albuminous  urine;  all  of  which  symptoms  may 
present  themselves  in  varying  degrees.  When  extreme,  and 
compensation  is  not  again  brought  about,  death  is  the  result. 

Physical  Signs. — Inspection  shows  displacement  of  the  apex 
beat  downward  and  to  the  left.  In  children  and  youths,  bulg- 
ing of  the  precordium  and  increased  cardiac  impulse  are  present. 
In  emaciated  individuals,  an  auricular  impulse  may  be  observed 
to  the  left  of  the  pulmonic  area  in  the  second  interspace. 

Palpation  serves  to  confirm  inspection.  The  displaced  car- 
diac impulse  is  forcible  and  diffused  in  the  early  stage;  as  com- 
pensation fails,  the  impulse  becomes  feeble  or  absent. 


AORTIC    REGURGITATION.  433 

Percussion  shows  an  increase  in  the  area  of  cardiac  dullness 
transversely  and  vertically. 

Auscultation  reveals  a  systolic  or  blowing  murmur,  heard  best 
in  the  mitral  area  and  transmitted  to  the  apex,  left  axilla,  and 
under  the  angle  of  the  scapula.  It  may  occur  with,  or  take  the 
place  of  the  first  sound  of  the  heart,  the  second  sound  being 
markedly  accentuated,  particularly  in  the  pulmonic  area. 

Prognosis. — So  long  as  the  compensating  hypertrophy  can  be 
maintained,  the  prognosis  is  not  unfavorable;  when  dilatation 
supervenes,  however,  the  patient  soon  perishes,  either  from  con- 
gestion of  the  lungs,  or  dropsy  and  exhaustion. 

AORTIC  REGURGITATION. 

This  is  also  termed  aortic  insufficiency,  and  occurs  next  in  fre- 
quency to  mitral  insufficiency.  It  is  the  most  serious  of  the 
ordinary  valvular  lesions. 

Pathologic  Anatomy. — The  valves  or  segments  adhere  to  the 
walls  of  the  aorta,  or  a  segment  is  lacerated  or  perforated,  or, 
more  commonly,  the  segments  are  shrunken,  deformed,  and 
rigid,  permitting  regurgitation  of  the  blood.  These  deficiencies 
a.re  usually  associated  with  more  or  less  dilatation  of  the  orifice. 

The  inability  of  the  aortic  valves  to  completely  close  the  aor- 
tic orifice  at  the  proper  moment  allows  the  blood  that  should  go 
onward  to  fiow  back  into  the  left  ventricle,  and  the  normal  flow 
of  blood  from  the  left  auricle  continuing,  causes  overfilling  of  the 
ventricle,  which  results  in  a  dilatation  of  its  cavity,  and  the 
extra  effort  of  the  ventricle  to  empty  itself  results  in  hyper- 
trophy of  the  walls.  •  In  no  other  condition  does  the  dilatation 
and  hypertrophy  of  the  cardiac  walls  reach  such  a  degree. 
The  older  writers  named  this  enormous  enlargement  of  the 
heart  "cor  hovinunt'  (see  Fig.   51). 

Symptoms. — So  long  as  the  cardiac  hypertrophy  is  just  suf- 
ficient to  compensate  for  the  valvular  condition,  there  are  no 
symptoms,  but  as  the  muscle  walls  continue  to  increase  symp- 
toms of  cardiac  hypertrophy  present  themselves,  such  as  forcible 
cardiac  action,  with  marked  pulsation  of  all  the  vessels  including 
28 


434 


AORTIC   REGURGITATION. 


"^Systole,  Diostole. 

Tricuspidl  Tricuspid 

Mitral       r^^'^nitrQl       T"" 
Aortic    -)^        Aortic      ^ 
Pulmonary  r^"PuLnionQri,r^^^ 


Fig.  44. — Position  of  the  valves  in  systole 
and  diastole.  {From  Greene's 
Medical  Diagnosis .) 


Fig.  45. — The  normal  heart  in  systole. 
The  full  ventricles  are  contracting,  the 
blood  flows  freely  from  them  into  the 
pulmonary  artery  and  aorta;  the  mitral 
and  tricuspid  valves  are  tightly  closed; 
the  auricles  are  refilling.  {From  Greene's 
Medical  Diagnosis.) 


Fig.  46. — The  normal  heart  in  dias- 
tole. The  ventricular  contraction  has 
ceased,  the  aortic  and  pulmonary  valves, 
tightly  closed,  are  shutting  off  and 
supporting  the  blood  column;  the 
ventricles  are  filling  from  the  open 
mitral  and  tricuspid  orifices  above. 
{From  Greene's  Medical  Diagnosis.) 


Fig.  47. — Mitral  and  tricuspid  regur- 
gitation.— Heart  in  systole.  Mitral  and 
tricuspid  valves  both  incompetent.  Re- 
sult.— Double  systolic  murmur,  enlarge- 
ment of  both  right  and  left  chambers, 
pulsating  jugulars,  general  venous  con- 
gestion, edema,  anasarca,  etc.  {From 
Greene's  Medical  Diagnosis .) 


M  V.  Mitral  valve,  t  v.  Tricusoid  valve,  a  v.  Aortic  valve,  p  v.  Pulmonary 
valve.  L  A.  Left  auricle.  R.  A.  Right  auricle.  L.  V.  Left  ventricle.  R.  V.  Right 
ventricle.  V  C  S.  Vena  cava  superior.  V  C  L  Vena  cava  inferior.  P  Vn.  Pulmonary 
veins.     P  A.  Pulmonary  artery.     A  O.  Aorta. 


AORTIC    REGURGITATION. 


435 


i^^^x^^^r. 


Mitral  Regurgitation. 


Fig.  48. — Mitral  regurgitation.  Four 
varieties  of  the  murmur  of  mitral  regur- 
gitation are  shown  graphically.  The 
heart  in  systole,  mitral  leakage  evident. 
The  contracting  ventricles  are  forcing 
the  blood  thrgugh  the  open  aortic  and 
pulmonary  valves;  the  tricuspid,  tightly 
closed,  prevents  regurgitation  into  right 
auricle.  The  leaky  mitral  allows  back- 
flow  into  the  left  auricle  already  filling 
from  the  pulmonary  veins  above.  Re- 
sults.— A  systolic  murmur,  dilatation  of 
left  auricle,  pulmonary  congestion,  and 
consequent  enlargement  of  right  ven- 
tricle. (From.  Greene's  Medical 
Diagnosis .) 


Fig.  50. — Aortic  stenosis.  Three 
varieties  of  the  aortic  systolic  murmur 
are  represented  graphically.  Diagram- 
matic representation  of  the  heart  in  sys- 
tole, stenosis  of  the  aortic  valve  being 
present;  the  mitral  and  tricuspid  valves 
have  closed ;  the  right  ventricle  is  nearly 
empty;  the  left  ventricle  is  still  more 
than  half  full  of  blood,  because  of  the 
obstruction  present  at  the  aortic  orifice. 
Result. — A  systolic  murmur  in  the  aortic 
area;  enlargement  of  left  ventricle,  etc. 
{From.  Greene's  Medical  Diagnosis.) 


Fig.  49. — Graphic  representation  of 
three  varieties  of  the  murmur  of  mitral 
obstruction.  Heart  at  moment  of 
auricular  contraction  immediately  before 
systole  (presystole) ;  mitral  obstruction 
evident;  aortic  and  pulmonary  valves 
closed;  tricuspid  freely  opened;  right 
auricle  nearly  empty;  right  ventricle 
filled;  left  auricle  but  partly  emptied; 
left  ventricle  barely  half  full.  Result. — 
Presystolic  or  diastoUc  murmur,  dilata- 
tion of  left  auricle,  congestion  of  lungs, 
consecutive  enlargement  of  right  heart. 
{From  Greene's  Medical  Diagnosis.) 


Fig.  51. — Graphic  representation  of 
murmur.  Two  varieties  of  aortic  diasto- 
Hc  murmur  shown  graphically.  The  heart 
is  shown  in  diastole,  aortic  leakage  being 
evident.  The  blood  has  just  been  pro  - 
jected  into  the  aorta  and  pulmonary 
artery  by  the  ventricular  contraction. 
The  pulmonary  valve  tightly  closed 
maintains  the  blood  column,  but 
through  the  leaky  aortic  valve  a  regur- 
gitant current  meets  the  stream  descend- 
ing from  above  through  the  open  mitral 
valve.  Results. — A  diastolic  murmur, 
dilatation,  and  hypertrophy  of  left  ven- 
tricle, a  slapping,  low- tension  ptolse. 
(From  Greene's  Medical  Diagnosis.) 


436  AORTIC   REGURGITATION. 

the  capillaries,  the  characteristic  forcible  and  receding  pulse 
("water-hammer  pulse,"  or  "  Corrigan  -  pulse  ") ,  headache,  in- 
somnia, tinnitus  aurium,  congestion  of  the  eyes  and  face,  etc. 

BRAIN 


CAPILLARIES 

Fig.  52. — Diagram  for  studying  the  results  of  backward  pressure.  Note  the  areas  in 
blue  will  become  the  seat  of  changes  consequent  on  venous  congestion.  {From 
Wheeler  and  Jack.) 

Precordial  pain  is  usually  present  in  aortic  disease.  It  may  be 
a  sensation  of  constriction  in  the  cardiac  region  or  it  may  con- 
sist of  sharp,  shooting  pains  "extending  to  the  arms — anginoid 


AORTIC   REGURGITATION.  437 

attacks.  As  soon  as  the  slightest  failure  of  compensation 
occurs,  the  cardiac  action  becomes  excessive  and  distressing. 
Palpitation  is  present  and  causes  anxiety  and  fear  on  the  part 
of  the  patient.  When  there  is  complete  rupture  of  compen- 
sation, there  develop,  either  gradually  or  rapidly,  dyspnea, 
increased  on  exertion,  cough,  cyanosis,  hepatic  enlargement, 
renal  congestion  with  scanty,  albuminous  urine,  ascites,  and 
dropsy.  If  mitral  insufficiency  is  now  superadded,  general 
venous  stasis  and  death  rapidly  follow.  Sudden  death  is  most 
frequent  in  this  form  of  vavular  heart  disease. 

Physical  Signs. — Inspection  shows  that  the  cardiac  impulse 
is  forcible  and  displaced  downward  and  to  the  left.  The  pulsa- 
tion is  visible  far  beyond  the  normal  apex. 

Palpation  confirms  inspection.  It  may  at  times  serve  to 
detect  a  diastolic  thrill  over  the  base  of  the  heart  and  the  adja- 
cent large  vessels.  The  Corrigan  pulse  and  the  capillary  pulse 
are  recognized  by  palpation. 

Percussion  serves  to  demonstrate  an  increase  in  the  area  of 
cardiac  dullness  downward  and  to  the  left.  Occasionally  it  is 
increased  upward  and  to  the  left  of  the  sternum  as  the  result  of 
hypertrophy  of  the  left  auricle. 

Auscttltation  reveals  characteristic  -  alterations  in  the  heart 
sounds.  The  first  sound  is  forcible;  the  second  sound  is  replaced 
or  associated  with  a  churning,  rushing,  or  blowing  murmur  of 
low  pitch,  well  heard  at  the  second  right  costal  cartilage  (aortic 
area)  but  most  distinct  at  the  junction  of  the  sternum  and  the 
fourth  left  costal  cartilage.  It  is  transmitted  downward  and 
toward  the  apex.  A  presystolic  rumbling  murmur  (Flint  mur- 
mur) may  occasionally  be  heard  over  a  limited  area  at  the  apex. 

Prognosis. — Sudden  death  is  more  liable  to  occur  in  this  than  in 
any  other  form  of  chronic  valvular  disease.  As  long,  however, 
as  the  compensating  hypertrophy  is  intact,  it  is  compatible  with 
quite  an  active  life.  The  outlook  is  largely  influenced  by  the 
condition  of  the  arterial  walls.  Obstruction  from  any  cause  in- 
duces rupture  of  compensation.  Next  to  the  tricuspid  regurgi- 
tation it  is  the  most  serious  of  all  chronic  valvular  conditions. 
Overexertion  influences  it  unfavorably. 


43  8  TRICUSPID   REGURGITATION. 

TRICUSPID  REGURGITATION. 

Pathologic  Anatomy. — This  form  of  valvular  insufficiency  is 
either  associated  with  right-sided  cardiac  dilatation  from  pul- 
monary obstruction,  or  is  the  result  of  mitral  disease.  The 
tricuspid  orifice  is  dilated  in  the  majority  of  cases;  occasionally 
the  segments  of  the  valves  are  contracted  or  adherent  to  the 
ventricle.  It  may  be  due  to  prenatal  endocarditis  or  to  endo- 
carditis in  childhood  (see  Fig.  47). 

Symptoms. — The  manifestations  of  this  condition  are  all  the 
result  of  venous  stasis,  and  include  jugular  pulsation  syn- 
chronous with  the  heart's  action,  hepatic,  renal,  and  pulmonary 
congestion,  pulsation  of  the  liver,  cyanosis,  dyspnea,  and 
obstinate  dropsy.  These  symptoms  are  superadded  to  those 
of  the  primary  or  associated  conditions. 

Physical  Signs. — Inspection  detects  a  diffused,  wavy,  cardiac 
impulse,  synchronous  with  the  heart's  action  and  uninfluenced 
by  respiration,  more  or  less  prominent  hepatic  pulsation,  cyan- 
osis, dyspnea,  and  edema. 

Palpation  shows  the  cardiac  impulse  to  be  feeble  and  extended 
downward. 

Percussion  reveals  hypertrophy  of  the  right  ventricle  as  is  evi- 
denced by  the  increased  area  of  cardiac  dullness  to  the  right  of 
and  below  the  sternum. 

Auscultation  serves  to  elicit  a  blowing  systolic  murmur  most 
intense  at  the  junction  of  the  fourth  and  fifth  ribs  with  the  ster- 
num. It  is  distinct  over  the  xiphoid  appendix  becoming  feeble 
or  lost  in  the  left  axillary  region.  It  is  often  associated  with  a 
mitral  systolic  murmur.     The  pulmonary  second  sound  is  weak. 

Prognosis. — This  is  the  most  unfavorable  variety  of  chronic 
valvular  disease  of  the  heart.  Dropsy,  dyspnea,  and  cyanosis 
persist  in  spite  of  treatment.  The  failure  to  restore  compensa- 
tion results  in  death. 

PULMONARY  REGURGITATION. 

Pathologic  Anatomy. — Insufficiency  of  the  pulmonary  valves 
is  of  rare  occurrence,  but  when  present,  the  changes  correspond, 
more  or  less,  with  those  described  under  aortic  regurgitation. 


MITRAL   OBSTRUCTION.  439 

Symptoms. — Most  of  the  symptoms  are  referable  to  dilatation 
of  the  right  side  of  the  heart  and  consequent  pulmonary  conges- 
tion, such  as  dyspnea,  cyanosis,  distention  of  the  superficial  ves- 
sels, palpitation  of  the  heart,  precordial  distress,  suffocative 
attacks,  and  dropsy. 

Physical  Signs. — Percussion  shows  extension  of  the  cardiac 
dullness  to  the  right  of  the  sternum. 

Auscultation  reveals  a  loud  blowing  diastolic  murmur  most 
distinct  at  the  junction  of  the  third  left  costal  cartilage  and  the 
sternum. 

Prognosis. — Death  results,  sooner  or  later,  from  dropsy  and 
exhaustion. 

MITRAL  OBSTRUCTION. 

Mitral  obstruction  or  stenosis  is  not  so  frequent  as  regurgita- 
tion, and  is  very  often  associated  with  the  latter.  It  may  be  en- 
countered as  a  single  affection  in  young  persons,  especially  fe- 
males. It  may  be  due  to  acute  or  chronic  endocarditis,  or  it 
may  occasionally  be  congenital. 

Pathologic  Anatomy. — Mitral  stenosis  is  caused  by  deposits 
around  the  orifice,  or  else  the  segments  of  the  valves  are  "  glued 
together  by  their  margins,"  leaving  but  a  funnel-shaped  opening, 
the  so-called  "buttonhole"  mitral  valve.  Vegetations  on  the 
valves  lead  to  more  or  less  obstruction  to  the  blood  current 
(see  Fig.  49). 

Symptoms. — The  obstructed  mitral  orifice  gives  rise  to  hyper- 
trophy of  the  left  auricle  which  in  time  is  followed  by  dilatation. 
The  symptoms  are  usually  unobservable  until  compensation 
ruptures,  which  is  manifested  by  small,  irregular,  and  feeble 
pulse,  dyspnea,  cough,  bronchorrhea,  and  dilatation  of  the 
right  side  of  the  heart  soon  leading  to  general  venous  stasis, 
dropsy,  and  death. 

Physical  Signs. — Inspection  shows  nothing  abnormal  until 
hypertrophy  of  the  left  auricle  occurs  when  an  undulatory 
impulse  is  observed  over  its  area.  Bulging  over  the  lower  part 
of  the  sternum  may  be  present. 


440  AORTIC    OBSTRUCTION. 

Palpation  serves  to  recognize  a  presystolic  thrill  near  the  apex 
(in  the  fourth  or  fifth  interspace  within  the  nipple-line).  When 
cardiac  dilatation  occurs,  a  diffused,  feeble,  and  irregular  car- 
diac impulse  is  felt  near  the  xiphoid  appendix. 

Percussion  may  demonstrate  increased  area  of  cardiac  dull- 
ness on  the  right  side. 

Auscultation  elicits  nothing  abnormal  in  the  first  or  the  second 
sound  except  possibly  disturbances  of  rhythm.  A  blowing, 
sometimes  rasping,  sound  is  heard,  immediately  after  the 
second  sound,  and  immediately  before  the  first  sound  begins, 
which  is  especially  characteristic.  This  presystolic  murmur  is 
heard  most  distinctly  in  the  mitral  area  lessening  in  intensity 
toward  the  base.  It  is  not  transmitted  but  is  occasionally 
heard  in  atypical  regions  such  as  the  axilla  and  angle  of  scapula. 
The  second  sound  in  the  pulmonary  area  is  accentuated.  As 
the  condition  reaches  its  terminal  stage,  the  murmur  may 
disappear  and  the  first  sound  becomes  snappy  in  character. 
With  the  onset  of  dilatation  all  the  heart  sounds  become  en- 
feebled. 

Prognosis. — The  outlook  depends  upon  whether  auricular  hy- 
pertrophy occurs  and  how  long  it  is  maintained.  Under  favor- 
able circumstances,  mitral  stenosis  is  compatible  with  a  long 
and  rather  active  life. 

AORTIC  OBSTRUCTION. 

Pathologic  Anatomy.- — Stenosis  of  the  aortic  orifice  is  caused 
by  the  projection  of  the  valves  inward,  and  their  becoming 
rigid  and  thickened,  atheromatous  or  calcareous,  so  that  they 
cannot  be  pressed  back  by  the  blood,  but  remain  constantly  in 
the  current  of  the  circulation.  Occasionally  the  valves  are 
covered  with  fibrinous  masses,  the  opening  into  the  artery 
being  thus  more  or  less  completely  closed,  or  the  segments  may 
be  adherent  by  their  lateral  surfaces,  leaving  a  central  opening, 
which  may  be  so  contracted  as  to  permit  the  passage  of  only 
the  smallest  probe.  Aortic  stenosis  is  nearly  always  a  disease 
of  advanced  life,  and  is  associated  with  the  arterial  changes  of 


AORTIC    OBSTRUCTION.  44 1 

age.      Uncomplicated    cases    are    rare.     Aortic    disease   is   not 
nearly    so    often    of    rheumatic    origin    as    mitral    disease   (see 

Fig.  50). 

Symptoms. — Hypertrophy  of  the  left  ventricle  rapidly  super- 
venes upon  aortic  stenosis,  and  so  long  as  the  cardiac  hyper- 
trophy is  just  sufficient  for  compensation,  there  will  be  no  sub- 
jective symptoms,  many  cases  of  stenosis  being  discovered  only 
when  the  individual  is  examined  for  insurance  or  other  pur- 
poses. The  pulse  is  small,  slow,  and  hard.  When,  however, 
the  compensatory  hypertrophy  begins  to  fail,  the  supply  of 
blood  to  the  brain  is  insufficient  in  many  cases,  and  pallor, 
with  attacks  of  vertigo,  syncope,  or  slight  epileptiform  seizures 
occur;  finally,  as  dilatation  of  the  left  ventricle  and  incompe- 
tence of  the  mitral  valve  result,  there  occur  pulmonary  conges- 
tion, dyspnea,  and  general  venous  stasis,  the  pulse  being  soft 
and  feeble. 

Physical  Signs. — Inspection  serves  to  detect  displacement  of 
the  apex  beat  downward  and  to  the  left  varying  with  the  degree 
of  hypertrophy. 

Palpation  confirms  inspection.  The  impulse  is  strong  in  the 
early  stage,  becoming  feeble  with  the  onset  of  dilatation. 

Percvission  shows  a  slight  increase  in  the  cardiac  dullness. 

Auscultation  reveals  characteristic  changes  in  the  heart- 
sounds.  The  first  sound  of  the  heart  is  replaced  or  associated 
with  a  harsh,  rasping  sound,  whistling  at  times,  having  its 
greatest  intensity  at  the  junction  of  the  second  right  costal 
cartilage  with  the  sternum,  transmitted  along  the  vessels;  the 
murmur  may  sometimes  be  heard  a  short  distance  from  the 
patient.  Usually,  aortic  stenosis  is  associated  with  more  or  less 
aortic  regurgitation,  whence  a  double  murmur  occurs,  having 
its  greatest  intensity  at  the  base  of  the  heart,  the  so-called 
io-and-fw ,  or  see-saw  murmur. 

Prognosis. — So  long  as  compensation  is  maintained  the  con- 
dition of  the  patient  is  comfortable,  if  a  quiet  life  be  followed. 
When  the  compensation  is  ruptured,  the  usual  symptoms  of 
dilatation,  venous  stasis,  and  dropsy  soon  ensue. 


442  PULMONARY   OBSTRUCTION. 

TRICUSPID  OBSTRUCTION. 

This  condition  is  one  of  the  rarest  affections  of  the  heart,  and 
if  it  ever  does  occur  with  or  following  an  attack  of  endocarditis, 
the  anatomical  changes  are  similar  to  those  of  mitral  obstruc- 
tion. It  produces  enlargement  of  the  heart  transversely  and  is 
indicated  by  a  presystolic  murmur  at  the  base  of  the  ensiform 
cartilage.  This  condition  soon  leads  to  auricular  dilatation; 
venous  stasis  rapidly  supervenes,  associated  with  venous  pul- 
sations similar  to  those  described  when  speaking  of  tricuspid 
regurgitation. 

PULMONARY  OBSTRUCTION. 

Pathologic  Anatomy. — Pulmonary  obstruction  is  always  a  con- 
genital malady  and  may  be  found  associated  with  constriction  of 
the  pulmonary  artery,  patulous  foramen  ovale,  patulous  ductus 
Botalli,  or  stricture  of  the  ductus  Botalli.  Hypertrophy  of  the 
right  ventricle  may  ensue.  Those  in  whom  these  congenital 
cardiac  conditions  occur  are  otherwise  weak,  develop  slowly, 
have  flabby  tissues  and  soft  bones,  and  seem  poorly  nourished. 

Symptoms. — The  hypertrophy  which  often  occurs  serves  to 
establish  compensation,  failure  of  which  as  in  other  valvular 
defects  results  in  cough,  dyspnea,  cyanosis,  and  death.  The 
physical  signs  reveal  marked  enlargement  of  the  right  ventricle 
and  a  systolic  murmur  in  the  second  left  intercostal  space  which 
is  not  transmitted,  and  a  systolic  thrill  in  the  pulmonary  area. 

Prognosis. — The  duration  of  these  congenital  affections  is 
short,  usually  from  a  few  days  to  a  few  months;  although 
several  well-authenticated  cases  record  a  much  longer  duration. 

RELATIVE  FREQUENCY  OF  VALVULAR  DEFECTS. 

The  order  of  frequency  is  practically  that  given  by  F.  J. 
Smith : 

1.  Mitral  incompetency. 

2.  Mitral  stenosis.  ]    r^r  j.-      ^^  ^  r 

...  Of  practically  equal  frequency. 

3.  Aortic  incompetency.  J 

4.  Aortic  stenosis. 


COMBINED    VALVULAR    LESIONS.  443 

5.  Tricuspid  stenosis. 

6.  Tricuspid  incompetency. 

7.  Pulmonary  stenosis. 

8.  Pulmonary  incompetency. 

COMBINED  VALVULAR   LESIONS. 

Smith's  list  is  as  follows: 

1.  Aortic  incompetency  and  stenosis;  mitral  incompetency. 

2.  Aortic  stenosis  and  mitral  incompetency. 

3.  Aortic  incompetency  and  mitral  incompetency. 

(There  is  less  than  i  per  cent,  difference  in  the  frequency 
of  2  and  3.) 

4.  Aortic    incompetency   and   stenosis,    with    mitral   stenosis 

and  incompetency. 

5.  Mitral  incompetency  and  tricuspid  incompetency. 

6.  Aortic    incompetency    and    stenosis,    with    mitral  incom- 

petency   tricuspid  incompetency. 

DIAGNOSIS   AND   TREATMENT   OF  VALVULAR   DISEASES. 

In  making  a  differential  diagnosis  between  the  various  forms 
of  valvular  disease  of  the  heart,  strict  attention  must  be  paid 
to  the  points  of  greatest  intensity  at  which  the  several  mur- 
murs are  heard. 

A  murmur  occurring  with  or  taking  the  place  of  the  first  sound 
of  the  heart — the  ventricular  systole — heard  most  distinctly  at 
the  apex,  transmitted  to  the  left  axilla  and  to  the  inferior  angle 
of  the  scapula — a  mitral  systolic  murmur — signifies  m-itral  regurgi- 
tation. 

A  murmur  occurring  with  or  taking  the  place  of  the  first  sound 
of  the  heart,  with  its  point  of  greatest  intensity  at  the  xiphoid 
appendix — a  tricuspid  systolic  murmur — signifies  tricuspid 
regurgitation. 

A  murmur  heard  with  the  first  sound  of  the  heart,  high- 
pitched,  rasping,  or  grating  in  character,  with  its  point  of  greatest 
intensity  at  the  second  right  costal  cartilage — an  aortic  systolic 
m^urmur — signifies  aortic  obstruction. 


444         DIAGNOSIS  AND    TREATMENT    OE    VALVULAR   DISEASES. 

A  murmtir  heard  with  the  first  sound  of  the  heart,  soft  in 
character,  with  its  point  of  greatest  intensity  at  the  junction  of 
the  third  left  costal  cartilage  with  the  sternum — a  pulmonic  sys- 
tolic murmtir — signifies  pulmonary  obstruction. 

A  murmur  occurring  immediately  after  the  second  sound  and 
immediately  before  the  beginning  of  the  first  sound  of  the  heart — 
a  presystolic  fnitral  murmur — signifies  mitral  obstruction. 

A  murmur  heard  with  or  taking  the  place  of  the  second  sound 
of  the  heart,  most  distinct  at  the  second  costal  cartilage,  to  the 
right  of  the  sternum,  and  well  transmitted  toward  the  apex  or 
below — an  aortic  diastolic  murmur — signifies  aortic  regurgitation. 

Although  eight  distinct  valvular  murmurs  have  been  de- 
scribed as  occurring  in  the  heart,  those  on  the  right  side  are  of 
rare  occurrence,  and  hence  of  little  clinical  importance. 

If  a  murmur  be  heard  with  the  first  sound  of  the  heart,  it  is 
almost  certainly  aortic  obstructive  or  mitral  regurgitant;  and  if 
heard  with  the  second  sound,  it  is  probably  aortic  regurgitant.  A 
presystolic  mitral  murmur  is  also  of  comparatively  rare  occur- 
rence, the  force  with  which  the  blood  passes  from  the  left 
auricle  into  the  left  ventricle  being,  under  ordinary  circum- 
stances, insufficient  to  excite  sonorous  vibrations. 

Functional  or  hemic,  or  anemic  murmurs  may  be  confounded 
with  the  various  forms  of  valvular  disease  of  the  heart.  The 
chief  points  of  distinction  between  them  are  that  a  hemic  mtir- 
mur,  which  is  always  heard  at  the  base  'of  the  heart,  is  always 
systolic  in  time,  not  transmitted  away  from  the  heart,  and  is  soft 
in  character,  low  in  pitch,  and  of  variable  intensity,  now  being 
heard,  now  entirely  absent. 

Treatment. — There  is  no  special  treatment  for  each  individual 
form  of  valvular  heart  disease.  According  to  Da  Costa,  the 
following  should  govern  the  treatment : 

I.  The  state  of  the  heart-muscle  and  of  the  cavities.  2.  The 
rhythm  of  the  heart-action.  3.  The  condition  of  the  arteries 
and  veins  and  of  the  capillary  system.  4.  The  probable  length 
of  existence  of  the  malady  and  its  likely  cause.  5.  The  general 
health.      6.   The  secondary  results  of  the  cardiac  affection. 

For  practical  purposes,  it  may  be  considered  that  if  the  apex- 


DIAGNOSIS   AND    TREATMENT    OF    VALVULAR    DISEASES.         445 

beat  is  not  displaced,  cardiac  dullness  is  not  enlarged  to  the  right 
of  the  sternum,  and  dyspnea  is  not  present,  medication  is  not 
indicated  and  may  even  be  injurious.  If,  on  the  other  hand, 
symptoms  of  hypertrophy,  dilatation,  or  failure  of  compensation 
of  the  heart  are  present,  treatment  should  be  instituted  at  once. 

In  all  cases,  however,  the  patient  should  be  warned  against 
excessive  physical  exertion  such  as  rapid  walking  or  running, 
ascending  stairs  quickly,  excessive  work,  etc.,  extremes  of  pas- 
sion, exposure  to  cold  and  wet,  and  irregular  living.  The 
occurrence  of  acute  diseases  in  the  course  of  valvular  defects 
cause  them  to  become  serious  affections  and  every  rheans  should 
be  taken  to  prevent  them.  The  Nauheim  treatment,  Oertel's 
method,  and  Swedish  movements  may  be  of  great  value  during 
the  compensation  stage. 

The  special  therapeutic  measures  indicated  for  cardiac  hyper- 
trophy and  cardiac  dilatation  are  considered  under  those  condi- 
tions. If  the  hypertrophy  necessar}^  to  maintain  compensation 
becomes  excessive,  aconite,  veratrum  viride,  or  nitroglycerin  is 
indicated.  If  dilatation  has  occurred,  the  heart's  action  is 
weak  and  feeble,  the  circulation  is  impeded,  and  venous  stasis 
has  followed,  digitalis,  caffein,  strophanthus,  and  spartein 
together  with  more  or  less  active  purgation  are  indicated.  Rest 
is  of  value  in  all  cardiac  conditions.  When  compensation  fails, 
rest  is  an  absolute  indication.  The  diet  should  be  liquid,  pref- 
erably milk,  as  the  passive  congestion  of  the  entire  digestive 
tract  interferes  greatly  with  assimilation.  The  heart  balance 
is  best  restored  by  the  administration  of  some  preparation  of 
digitalis  such  as  the  infusion,  oi  to  oiv  (4  to  15  c.c),  the  tincture, 
rr^v  to  XXX  (0.31  to  1.85  c.c),  or  the  powder,  gr.  i  (0.065  g^^-). 
three  times  daily.  The  possibility  of  nausea  following  the  use 
of  digitalis,  especially  the  tincture,  should  be  remembered.  The 
dose  of  the  drug  is  best  guided  by  the  results  it  produces.  When 
for  any  reason  digitalis  is  not  applicable,  strophanthus,  strych- 
nin, caffein,  and  spartein  may  be  given.  The  venous  engorge- 
ment and  dropsy  may  be  relieved  by  the  administration  of 
small  doses  of  mercury  and  saline  purgatives.  The  combination 
of  calomel,   digitalis,   and  squill,   of  each   gr.   i   (0.065   gi^-).   is 


446  HYPERTROPHY  OF  THE  HEART. 

especially  valuable  in  this  connection.  When  the  dropsy  is 
extreme,  tapping  or  multiple  incisions  may  be  required.  The 
extreme  and  distressing  shortness  of  breath  is  best  relieved  by 
morphin,  gr.  1/4  (0.0165  gii^-)>  ^^d  inhalations  of  oxygen.  The 
various  coal-tar  hypnotics  may  be  employed  but  are  less  effi- 
cient. When  the  cardiac  rhythm  is  disturbed  from  any  cause, 
tincture  of  belladonna,  rixv  to  xv  (0.31  to  0.92  c.c),  a  belladonna 
plaster  over  the  precordium,  or  nitroglycerin,  gr.  i/ioo 
(0.00065  gii^-).  should  be  employed  in  addition  to  other  treat- 
ment. Sudden  failure  of  the  heart  requires  the  prompt  admin- 
istration of  diffusible  stimulants  such  as  aromatic  spirit  of 
ammonia,  whiskey,  nitroglycerin,  ether,  etc.  Ammonia  and 
nitrite  of  amyl  should  be  inhaled  while  the  other  remedies  should 
be  given  hypodermically. 

In  all  cases  in  which  the  general  health  fails  and  weakness  and 
emaciation  present  themselves,  resort  should  be  had  to  tonics 
such  as  iron,  quinin,  and  arsenic  in  addition  to  the  other 
measures. 


DISEASES  OF  THE  MYOCARDIUM. 
HYPERTROPHY  OF  THE  HEART. 

Definition. — An  overgrowth  or  increase  in  the  muscular  tissue 
which  forms  the  walls  of  the  heart,  characterized  by  forcible 
impulse,  over-fullness  of  the  arteries,  diminished  blood  in  the 
veins,  and  accelerated  circulation. 

Causes. — It  is  most  frequently  caused  by  obstruction  to  the 
outflow  of  blood  such  as  results  from  valvular  disease  of  the 
heart,  emphysema,  Bright's  disease,  and  arteriosclerosis,  but  it 
may  also  be  due  to  excessive  functional  activity,  such  as  pro- 
duced by  prolonged  muscular  exertion,  exophthalmic  goitre,  the 
long-continued  use  of  large  amounts  of  tea,  coffee,  and  tobacco, 
and  attempts  to  overcome  pericardial  adhesions. 

Varieties. — I.  Simple  hypertrophy,  or  a  simple  increase  in  the 
thickness  of  the  cardiac  walls;     II.  Eccentric  hypertrophy,  in- 


HYPERTROPHY  OF  THE  HEART.  447 

crease  in  the  cardiac  walls  and  dilatation  of  the  cavities,  causing 
a  dilated  hypertrophy ;  III.  Concentric  hypertrophy,  increase  in 
the  cardiac  walls  with  decrease  of  the  cavities,  a  very  rare  form. 

Pathologic  Anatomy. — Hypertrophy  of  the  heart  is  usually 
limited  to  the  left  side,  the  ventricles  being  more  commonly  in- 
volved than  the  auricles,  the  latter  dilating.  The  shape  of  the 
heart  is  altered  by  hypertrophy;  if  the  right  ventricle,  the  heart 
is  widened  transversely  and  the  apex  blunted;  if  the  left  ven- 
tricle, the  heart  is  elongated  and,  as  a  rule,  the  cavity  is  dilated; 
if  both  ventricles  are  hypertrophied,  the  heart  has  a  globular 
shape.  From  increase  in  weight  the  heart  may  fall  back  during 
the  recumbent  position,  thereby  lessening  the  area  of  cardiac 
dullness,  but  during  the  sitting  or  upright  posture  it  sinks 
lower  in  the  chest  and  to  the  left,  causing  more  or  less  promin- 
ence of  the  abdomen.  The  increase  in  the  size  of  the  organ  is  a 
true  increase  or  hypertrophy  of  the  muscular  tissue,  and  not  a 
hyperplasia.  The  tissue  is  firmer  and  the  color  brighter  and 
fresher  than  when  the  size  of  the  organ  is  normal.  The  cor 
bovinum  of  the  old  writers  is  an  enormous  hypertrophy  of  the 
heart  with  dilatation  of  its  cavities. 

Symptoms. — These  depend  upon  the  amount  of  hypertrophy. 
If  only  sufficient  to  compensate  for  valvular  defects  or  other  cir- 
culatory disturbances  there  will  be  no  symptoms.  When  the 
enlargement  is  disproportionate  to  the  obstruction,  it  is  mani- 
fested by  increased  and  forcible  cardiac  action,  precordial 
discomfort,  headache,  dizziness,  ringing  in  the  ears,  flushes  or 
flashes  of  light,  dyspnea  on  exertion,  congestion  of  the  face  and 
eyes,  dry  cough,  epistaxis,  and  restless  nights,  with  more  or 
less  jerking  of  the  limbs.  The  arteries  become  full  and  the  pulse 
is  firm  and  bounding.  The  carotids  and  superficial  arteries 
pulsate  markedly,  the  patient  frequently  complaining  of  throb- 
bing sensations.  A  sphygmographic  tracing  shows  the  line  of 
ascent  vertical  and  abrupt,  but  the  apex  is  rounded,  and  the 
line  of  descent  is  oblique,  unless  there  is  more  or  less  insufficiency 
of  the  valves. 

Physical  Signs. — Inspection  reveals  fullness  or  prominence  of 
the  precordium  with  a  distinct  impulse. 


448  HYPERTROPHY  OF  THE  HEART. 

Palpation  detects  the  impulse  one  or  two  intercostal  spaces 
lower  down  and  to  the  left.  It  is  stronger  and  more  or  less 
diffused — the  heaving  impulse. 

Percussion  determines  an  increase  in  the  area  of  cardiac  dull- 
ness vertically  and  transversely  on  the  left  side  of  the  sternum, 
unless  the  right  ventricle  is  also  hypertrophied,  when  the  cardiac 
dullness  is  increased  to  the  right  of  the  sternum.. 

Auscultation  in  simple  hypertrophy  without  any  valvular 
changes,  detects  a  loud  first  sound  of  a  somewhat  metallic 
quality,  the  second  sound  being  strongly  accentuated.  In  the 
presence  of  valvular  disease  the  characteristic  murmurs  are 
heard  in  addition. 

Sequels. — Cerebral  hemorrhage,  miliary  cerebral  aneurysms, 
cardiac  dilatation,  and  fatty  degeneration  may  be  mentioned  as 
the  most  common  sequels. 

Diagnosis.— The  history,  course,  symptoms,  and  physical 
signs  are  distinctive  and  when  carefully  considered  should 
prevent  error  in  diagnosis. 

Prognosis. — When  it  is  the  result  of  valvular  disease,  the  hy- 
pertrophy is  said  to  be  compensatory.  If  the  result  of  Bright's 
disease,  emphysema  of  the  lung,  or  if  occurring  late  in  life,  or 
associated  with  atheromatous  degeneration  of  the  vessels,  the 
prognosis  is  unfavorable.  When  it  is  the  result  of  functional 
overacting  in  the  strong  and  robust,  a  further  enlargement  can 
often  be  prevented  by  active  and  persistent  treatment. 

Treatment. — When  the  hypertrophy  is  excessive,  the  indica- 
tions are  to  remove  the  cause  if  possible  and  to  lessen  the  force 
and  number  of  the  cardiac  pulsations. 

The  habits  of  the  patient  should  be  corrected;  all  laborious 
or  active  exertion  should  be  restricted  and  the  recumbent  pos- 
ture should  be  assumed  several  hours  during  the  day,  if  possible. 
The  diet  should  be  regulated,  and  all  forms  of  stimulants  such 
as  liquors,  tobacco,  tea,  and  coffee  should  be  interdicted.  Cases 
of  cardiac  hypertrophy  associated  with  Bright's  disease  are 
often  relieved  by  digitalis.  In  rare  instances  cardiac  pain 
follows  the  use  of  digitalis;  in  such  cases,  citrated  caffein  or 
strophanthus  are  to  be  employed.      AVhen  the  hypertrophy  is 


DILATATION    OF    THE   HEART.  449 

associated  with  anemia,  iron  should  be  administered  in  addition 
to  other  measures. 

The  force  and  frequency  of  the  cardiac  pulsations  are  best  con- 
trolled by  the  long-continued  use  of  tincture  of  aconite,  rr[y 
(0.3  c.c),  three  times  daily,  or  tincture  of  veratrum  viride,  n^x 
(0.6  c.c),  three  times  daily,  together  with  the  administration  of 
saline  purgatives,  bromids,  and  nitrites  to  lessen  the  arterial 
tension  and  to  relieve  the  symptoms. 


DILATATION  OF  THE  HEART. 

Definition. — An  increase  in  the  size  of  one  or  more  of  the 

cavities  of  the  heart,  characterized  by  feebleness  of  the  circula- 
tion, terminating  in  venous  stasis,  cyanosis,  edema,  and  ex- 
haustion. 

Causes. — It  is  usually  brought  about  by  chronic  valvular  heart 
disease,  emphysema,  chronic  bronchitis,  gout,  Bright 's  disease, 
alcoholism,  or  syphilis,  but  may  be  due  to  overexertion  in  those 
of  feeble  resisting  powers,  such  as  youths  and  soldiers. 

Varieties. — I.  Simple  dilatation,  the  cavities  being  enlarged, 
the  walls  normal.  II.  Active  dilatation,  corresponding  to  eccen- 
tric hypertrophy;  the  cavities  being  enlarged  and  the  walls  in- 
creased in  thickness,  the  so-called  "  dilated  hypertrophy." 
III.  Passive  dilatation,  the  cavities  being  enlarged  and  the  walls 
thinned  or  stretched. 

Pathologic  Anatomy. — The  right  side  of  the  heart  is  far 
more  frequently  involved  than  the  left  side.  The  shape  of  the 
organ  is  altered,  depending  on  the  part  affected.  The  weight  of 
the  organ  is,  as  a  rule,  increased,  as  hypertrophy  almost  always 
accompanies  or  precedes  dilatation.  The  muscular  tissue  is  gen- 
erally pale,  mottled,  and  softened,  and  under  the  microscope  pre- 
sents evidences  of  degeneration.  The  orifices  also  participate, 
and  especially  the  auriculo- ventricular  orifice,  resulting  in  the 
valves  becoming  incompetent  to  "close  the  orifices,  and  this 
latter  effect  is  increased  by  the  removal  of  the  basis  of  the  papil- 
lary muscles  a  greater  distance  from  the  orifice,  in  consequence  of 
29 


450  DILATATION    OF    THE   HEART. 

the  distention  of  the  wall.  When  the  auricles  dilate,  the  large 
venous  trunks  opening  into  them,  unprotected  by  valves,  com- 
monly participate  in  the  dilatation,  and  may  become  greatly 
enlarged.  The  passive  congestion  of  the  organs  that  follows 
the  enfeeblement  of  the  circulation  produces  changes  in  their 
structure. 

Symptoms. — The  manifestations  are  referable  to  the  enfeebled 
circulation  and  include  feeble  pulse,  headache  aggravated  by 
the  upright  position,  attacks  of  syncope,  cough,  dyspnea,  jaun- 
dice, dyspepsia,  constipation,  scanty,  often  albuminous  urine, 
mental  dullness,  vertigo,  often  relieved  by  a  copious  epistaxis, 
and  finally  dropsy  beginning  in  the  lower  extremities.  The 
condition  terminates  in  death  by  exhaustion.  Treatment 
may  serve  to  temporarily  relieve  any  of  the  symptoms  just 
mentioned. 

Physical  Signs. — Inspection  detects  enlargement  and  disten- 
tion of  the  superficial  veins  and  an  indistinct,  often  wavy  and 
diffused,  cardiac  impulse.  If  tricuspid  regurgitation  is  pres- 
ent, jugular  pulsation  will  be  observed. 

Palpation  confirms  inspection;  the  impulse  is  feeble,  irregular, 
and  heaving. 

Percussion  serves  to  determine  extension  of  the  area  of  cardiac 
dullness  transversely  and  especially  toward  the  right  side. 

Auscultation  in  the  presence  of  valvular  lesions  reveals  char- 
acteristic murmurs.  If  there  are  no  valvular  lesions,  the  car- 
diac sounds  are  weaker  than  normal  and  the  first  sound  is 
sharper  in  quality  than  usual. 

Diagnosis. — Hypertrophy  of  the  heart  shows  increased  cardiac 
dullness  and  is  a  disease  of  powerful  cardiac  action,  while  dila- 
tation is   an  affection  of  feeble  action  associated  with  dropsy. 

Pericardial  effusion  has  many  points  of  resemblance  to  car- 
diac dilatation,  but  it  begins  suddenly,  associated  with  some 
acute  malady,  and,  while  the  heart  sounds  are  indistinct  or 
feeble  at  the  apex,  they  both  have  their  normal  qualities  at  the 
cardiac  base,  while  dilatation  of  the  heart  has  a  chronic  history, 
and  results  in  general  venous  stasis,  the  cardiac  sounds  being 
of  the  same  intensity  over  the  entire  precordium." 


DILATATION    OF    THK    HEART.  45 1 

Prognosis. — The  outlook  is  unfavorable.  Death  results 
gradually  from  exhaustion  or  suddenly  from  cardiac  paralysis 
induced  by  some  undue  excitement. 

Treatment. — Dilatation  of  the  heart  is  incurable.  The  symp- 
toms may,  however,  be  temporarily  relieved  and  the  course  pro- 
longed. In  all  cases  the  indications  are  to  improve  and  main- 
tain the  general  nutrition  of  the  patient  and  to  control  and 
steady  the  cardiac  action. 

The  first  indication  is  met  by  a  generous  diet,  moderate  exer- 
cise, and  the  administration  of  stomachics,  red  wine,  iron,  etc. 

The  second  indication  is  met  by  strict  observance  of  the  rules 
of  hygiene,  by  moderate  exercise,  and  by  the  administration  of 
heart  tonics  such  as  digitalis.  This  drug  may  be  used  in  the 
form  of  powder,  tincture,  or  infusion,  or  in  the  following  com- 
bination: 

I^.      Tincturae  nucis  vomicae .  .    foss  15.  c.c. 

Tincturag  digitalis f  5ss  15.0.0. 

M.  S. — Fifteen  drops  after  meals,  in  water. 

The  combination  of  tincture  of  strophanthus  with  digitalis  is 
very  beneficial.  Strychnin  sulphate,  gr.  1/24  (0.0025  gm.),  three 
times  daily,  citrated  caffein,  gr.  i  to  iii  (0.06  to  0.2  gm.j,  three 
times  daily,  and  spartein  sulphate,  gr.  1/8  to  i  (0.0081  to 
0.065  g^^-)>  three  times  daily,  are  also  valuable  heart  tonics  and 
stimulants.  Morphin  sulphate,  in  small  doses  hypodermically, 
often  acts  like  magic  in  restoring  the  circulation  (Bartholow) 
especially  when  compensation  is  failing,  and  dropsy  and  cyano- 
sis become  marked. 

The  following  pill  is  often  of  great  advantage: 

I^.      Ferri  redact gr.  j  to  ij  .065  to  .  13  gm. 

Quininse  sulph gr.  j  to  ij  .065  to  .  13  gm. 

Pulv.  digitalis g^-  j  .065  gm. 

Morphinse  sulph ...  .  gr.  1/24  .0025  gm. 

M.  S. — Three  times  a  day. 


452  DILATATION    OF    THE   HEART. 

An  excellent  combination  is  the  following: 

I^.     Tinct.  digitalis f5iss.  6.c.c. 

Tinct.  cacti  grandiflor ..  .    f§j  30.  c.c. 

Caffeinae  citratae 3j  4-  gm- 

Tinct.  card,  comp.q.  s.  ad  fgivq.  s.  ad      120.  c.c. 
M.  S. — Teaspoonful,  diluted,  three  or  foirr  times  daily. 

The  bowels,  skin,  and  kidneys  should  be  kept  in  action,  using, 
if  needed,  purgatives,  diaphoretics,  and  diuretics.  The  following 
combination,  suggested  by  Dr.  J.  M.  Anders,  is  satisfactory  in 
many  instances: 

I^.     Caffeinae  citratae oj  4-         gm- 

Strychninae  sulph gr.  1/3  .022  gm. 

Sparteinae  sulph.  .' gr-  ij  .13     gm. 

M.     Ft.  capsul£e  No.  xij. 

S. — One  every  three  or  four  hours. 

Or  the  following  excellent  duiretic  pill : 

I^.     Pulv.  scillse gr.  xxk  2  .     gm. 

Pulv.  digitalis gr.  xxx  2  .     gm. 

Caffeinae  citratae gr.  xxx  2  .     gm. 

Hydrarg.  chlor.  mitis  .  .  .    gr.  v  .3  gm. 
M.     Ft.  pilulae  No.  xxx. 
S. — One  three  or  four  times  daily. 

The  development  of  pulmonary  congestion  calls  for  the  use 
of  dry  cups,  digitalis,  caffein,  atropin,  and  stimulants.  For 
hepatic  congestion,  blue  mass  and  popophyllin  are  indicated. 
Cardiac  asthma  may  be  relieved  to  a  great  extent  by  dry 
cups,  morphin  (hypodermically),  or  Hoffman's  anodyne.  The 
dropsy  may  be  lessened  by  dry  cups  over  the  kidneys,  digitalis, 
potassium  acetate,  scoparius,  preparations  of  juniper  berries, 
and  compound  jalap  powder.  If  the  dropsy  is  uninfluenced 
by  these  means,  calomel,  gr.  iii  (0.2  gm.),  guarded  by  powdered 
opium,  gr.  1/12  (0.005  gm.),  three  times  daily,  should  be 
employed. 

The  treatment  of  cardiac  dilatation  and  cardiac  failure  by 
baths  and  systematic  exercise  has  excited  much  interest  and  dis- 


ACUTE    MYOCARDITIS.  453 

cussion  recently,  with  the  result  of  its  indorsement  in  certain 
cases.  Exercise  is  employed  in  one  of  three  methods  or,  rarely, 
a  combination  of  these:  (i)  passive  exercise  and  massage  (Swed- 
ish or  Ling  plan;  (2)  movements  with  limited  resistance  (Schott 
plan,  but  really  a  modification  of  the  Swedish);  (3)  method  of 
climbing  (Oertel).  The  baths  are  those  of  the  Nauheim  (saline) 
natural  waters.  A  number  of  American  and  English  clinicians 
report  good  results  with  artificial  Nauheim  baths.  This  system 
of  cardiac  treatment  is  combined  with  regulated  diet,  business 
rest,  and  the  use  of  some  cardiac  tonics. 

ACUTE  MYOCARDITIS. 

Synonyms. — Carditis;  abscess  of  the  heart. 

Definition. — An  inflammation  of  the  muscular  tissue  of  the 
heart,  characterized  by  pain,  feeble  circulation,  symptoms  of 
blood-poisoning,  and  collapse. 

Causes. — It  nearly  always  arises  as  the  result  of  some 
general  septic  condition  such  as  pyemia,  septicemia,  typhoid 
fever,  puerperal  fever,  etc.,  but  it  may  be  due  to  extension  from 
a  septic  pericarditis  or  endocarditis. 

Pathologic  Anatomy. — The  structural  changes  consist  in  dis- 
coloration and  softening  of  the  cardiac  substance  with  infiltra- 
tion of  a  serosanguineous  fluid,  fibrinous  exudation,  and  pus, 
leading  ultimately  to  abscess  formation  in  the  myocardium. 
The  affection  terminates  in  either  cardiac  aneurysm  or  rupture 
of  the  heart.  In  the  event  of  recovery,  depressed  cicatrices  or 
scars  will  be  found  marking  the  sites  of  former  abscesses. 

Symptoms. — The  clinical  evidences  of  inflammation  of  the 
cardiac  muscles  are  very  vague.  If,  during  the  course  of  one  of 
the  maladies  mentioned,  there  are  developed  precordial  pain, 
irregular  and  feeble  cardiac  action,  cardiac  dyspnea,  pyrexia 
of  a  low  type,  with  symptoms  of  blood-poisoning  and  a  tendency 
to  collapse,  or  the  symptoms  of  the  so-called  typhoid  state, 
myocarditis  may  be  suspected. 

Diagnosis. — The  diagnosis  is  seldom  made  before  death.  It 
may  be  presumed,  however,  if  in  the  course  of  septic  conditions, 
symptoms  of  heart  failure  occur. 


454  CHRONIC    MYOCARDITIS. 

Prognosis. — The  course  of  acute  myocarditis  is  very  rapid, 
death  being  the  usual  termination  in  from  three   to   five   days. 

Treatment. — Cardiac  stimulants  should  be  employed  freely  in 
addition  to  the  other  remedial  measures  indicated  by  the  gen- 
eral sepsis. 

CHRONIC  MYOCARDITIS. 

Synonyms. — Fibroid  heart;  chronic  interstitial  myocarditis; 
fibrous  myocarditis;  chronic  carditis;  cardiosclerosis. 

Definition. — A  slowly  developing  hyperplasia  of  the  inter- 
stitial connective  tissue  of  the  heart,  leading  to  induration  of  its 
substance;  characterized  by  shortness  of  breath  on  slight  exer- 
tion, attacks  of  tachycardia,  precordial  pain,  disordered  circula- 
tion, and  vertigo.  It  is  proper  to  state  that  many  cases  present 
no  s37'mptoms  whatever. 

Causes. — The  most  frequent  cause  is  sclerosis  of  the  coronary 
arteries,  leading  to  imperfect  blood  supply  to  the  cardiac  muscles. 
It  usually  occurs  in  the  aged  and  bears  a  direct  relation  to 
the  condition  of  the  arteries  throughout  the  body.  Among 
other  causes  may  be  mentioned  diseases  of  the  kidneys,  alco- 
holism, excessive  use  of  tobacco,  syphilis,  pericarditis,  endo- 
carditis, and  acute  myocarditis.  There  is,  undoubtedly,  often 
an  inherited  predisposition  to  fibroid  changes  in  the  vessels,  in 
which  case  the  causes  named  would  act  as  exciting  causes. 

Pathologic  Anatomy. — The  heart  is  enlarged  and  dilated  and 
its  structural  changes  may  be  diffused  or  limited  to  the  walls  of 
the  left  ventricle,  the  papillary  muscles,  or  the  septum.  Val- 
vular disease  may  be  present.  Atheroma  is  usually  present  in 
one  or  more  of  the  coronary  arteries  and  may  involve  the  aorta. 
Sudden  complete  closure  of  one  coronary  artery  in  the  course 
of  these  morbid  changes  is  usually  fatal. 

On  section  of  the  organ,  the-  cardiac  wall  will  be  found  to  cut 
with  distinct  resistance,  due  to  an  overgrowth  of  the  interfibril- 
lar  connective  tissue  and  the  development  of  new  fibrous  tissue. 
When  due  to  some  general  intoxication  as  accompanies  gout, 
syphilis,  alcoholism,  etc.,  these  changes  are  uniformly  distrib- 
uted, but  if  due  to  embolism,   thrombosis,    or  other  conditions 


CHRONIC    MYOCARDITIS.  455 

occluding  one  or  more  coronary  vessels  there  will  be' localized 
anemic  infarction  and  sclerosis.  On  microscopic  examina- 
tion, the  muscle  bundles  will  be  found  degenerated  and 
replaced  by  fibrous  tissue.  In  cases  due  to  syphilis,  the  ter- 
minal branches  of  the  coronary  arteries  are  narrowed  and 
sclerotic  to  the  point  of  obliteration.  The  inelastic  fibrous 
tissue  in  the  heart  is  often  insufficient  in  resisting  the  intracar- 
dial  pressure  and  gives  way,  resulting  in  aneurysm  of  the  heart. 
This  is  particularly  liable  to  occur  in  localized  cardiosclerosis. 

Symptoms. — The  great  majority  of  patients  having  chronic 
myocarditis  present  no  symptoms  until  an  extra  cardiac  effort  is 
demanded.  An  early  symptom  is  breathlessness  on  slight  exer- 
tion, with  either  cardiac  palpitation  or  a  feeble,  irregular  pulse. 
Vertigo  is  frequent  and  distressing,  increased  by  indigestion  and 
constipation.  Anginal  attacks  (cardiac  pain)  or  sensations  of 
constriction  or  pressure  over  the  precordium  are  frequent,  often 
following  some  exertion  or  an  attack  of  indigestion.  The  pulse 
rate  is  often  decreased  in  frequency  in  cases  which  present  no 
other  symptom.  A  frequent  symptom  is  syncope,  coming  with- 
out warning  or  after  sudden  exertion,  the  result  of  sudden 
failure  of  the  cerebral  circulation.  Among  other  periodical 
symptoms  are  cardiac  asthma,  pseudo-apoplectic  attacks, 
and  hepatic,  gastric,  and  nephritic  disorders.  As  the  fibroid 
changes  progress,  there  develop  progressive  weakness,  dyspnea, 
insomnia,  disordered  digestion,  and  cerebral  weakness,  often 
showing  itself  as  mania,  delusional  attacks,  or  dementia. 

Physical  Signs. — Inspection  and  palpation  recognize  a  feeble 
impulse  which  at  times  is  scarcely  appreciable. 

Percussion  detects  enlargement  of  the  area  of  cardiac  dullness 
due  to  the  dilated  hypertrophy  of  the  heart. 

Auscultation  shows  the  first  sound  of  the  heart  to  be  valvular 
in  quality,  the  booming  or  muscular  quality  having  disappeared. 
Murmurs  are  frequent  and  are  due  to  valvular  disease.  A  very 
characteristic  feature  is  irregularity  in  the  rhythm  and  force  of 
the  heart,  a  forcible  contraction  alternating  with  a  weak  con- 
traction.    Eventually  both   sounds  become   weak   and  feeble. 

Diagnosis. — The  points  of  value  in  arriving  at  a  diagnosis  are : 


456  CHRONIC    MYOCARDITIS. 

a  careful  study  of  the  first  sound  of  the  heart  at  the  apex;  the 
character  of  murmurs  if  present,  the  conditions  of  the  arteries, 
the  dyspnea,  the  feeble,  irregular  pulse  in  patients  past  fifty 
years,  and  the  occurrence  of  anginal  attacks  after  exertion  or 
mental  worry. 

Prognosis. — This  is  controlled  by  the  habits  of  the  patient. 
The  disease  is  incurable,  but  life  may  be  fairly  comfortable  for 
many  years  if  care  be  exercised.  It  should  be  remembered, 
however,  that  chronic  myocarditis  is  one  of  the  most  common 
causes  of  heart  failure  and  subsequent  death,  in  the  course 
of  acute  pneumonia,  typhoid  fever,  etc.,  and  after  overexertion 
of  any  kind. 

Treatment. — No  remedy  can  remove  the  fibroid  change. 
The  indications  are  to  promote  the  patient's  nutrition,  hold  in 
check  the  progress  of  the  fibrosis,  and  meet  or  prevent  the  symp- 
toms as  they  arise.  The  patient's  general  condition  requires 
the  administraton  of  iron,  arsenic,  and  the  hypophosphites. 
Constipation  should  be  avoided  by  the  use  of  aloes,  cascara,  or 
other  mild  laxative.  Mental  strain  and  physical  exertion  should 
be  carefully  guarded  against  and  tobacco  and  malt  liquors 
should  be  interdicted.  The  diet  must  be  plain  with  but  little 
tea  or  coffee.  In  the  elderly,  a  small  amount  of  good  whiskey 
once  or  twice  daily  is  valuable.  The  Nauheim  treatment  may 
be  of  great  benefit  and  is  worthy  of  a  trial. 

Relief  of  the  symptoms  is  usually  obtained  by  measures  di- 
rected toward  supporting  the  heart.  For  breathlessness,  spirit  of 
glonoin,  spirit  of  nitrous  ether,  and  aromatic  spirit  of  ammonia 
are  especially  indicated.  Cardiac  palpitation  may  be  relieved 
by  potassium  bromid,  lithium  bromid,  and  aromatic  spirit  of 
ammonia.  Weakness  of  the  heart  requires  the  administration 
of  strychnin  sulphate,  gr.  1/24  (0.0025  gm.),  three  times  daily; 
tincture  of  digitalis,  ttlx  to  xx  (0.6  to  1.2  c.c), three  times  daily;  or 
citrated  caffein,  gr.  iii  (0.2  gm.),  three  times  daily.  The  recum- 
bent position  should  be  assumed,  and  gastrointestinal  disturb- 
ances should  receive  prompt  treatment.  For  the  anginal  attacks 
hypodermic  injections  of  morphin  sulphate,  gr.i/8  to  1/4  (0.008 
to  0.016  gm.),  or  chlorodyne,  ttlx  to  xx  (0.6  to  1.2  c.c),  should  be 


FATTY   HEART.  457 

given,  repeated  as  needed.  When  syncopal  attacks  occur,  the 
patient  should  be  placed  in  bed  and  a  mustard  plaster  applied  to 
the  precordium;  stimulants,  especially  nitroglycerin,  should  be 
administered, preferably  by  hypodermic  injection.  The  following 
is  an  excellent  combination  for  the  relief  of  dyspnea,  vertigo, 
and  chest  pains: 

I^.      Lithii  bromidi 5vss  22  .  gm. 

Spiritus  glonoini    nix"^j  ^  •  ^.c. 

Liq.  potassii  citratis 

q.s.  ad  f  oviij  ad  240.  c.c. 

M.  S. — Tablespoonful  four  times  daily,  diluted. 

FATTY  HEART. 

Synonyms. — Fatty  degeneration  of  the  heart;  chronic  myo- 
carditis. 

Definition. — A  change  in  the  muscular  fibers  of  the  heart,  in 
which  the  transverse  striae  are  replaced  by  granules  and  globules 
■of  fat,  characterized  by  feeble  cardiac  action,  venous  stasis,  and 
dyspnea. 

Causes. — The  most  important  factors  in  the  production  of  this 
condition  are  impaired  nutrition  in  the  elderly,  prolonged  anemia, 
chronic  gout,  alcoholism,  phosphorous  poisoning,  cancer,  tuber- 
culosis, and  disease  of  the  coronary  arteries. 

Pathologic  Anatomy. — Fatty  degeneration  should  be  distin- 
guished from  fatty  infiltration;  in  the  latter,  the  adipose  tissue  is 
deposited  on  the  organ  and  between  its  muscular  fibres.  This 
condition  is  to  some  extent  normal  and  accompanies  general 
obesity. 

Fatty  degeneration  affects  the  individual  muscle  fibers;  the 
changes  being  within  and  not  between  the  fibers.  The  fatty 
metamorphosis  may  affect  the  whole  organ,  or  the  entire  ventric- 
ular walls,  or  may  be  limited  to  portions  of  them.  If  the  degener- 
ation be  marked,  the  color  is  yellowish,  the  tissues  soft  and  easily 
torn,  and  to  the  touch  have  a  greasy  feeling,  oil  being  yielded  on 
pressure. 

The  microscopic  changes  are  characteristic.     The  stri«  of  the 


458  FATTY  HEART. 

muscle  are  rendered  indistinct  by  fat  and  oil  globules,  gradually 
becoming  more  and  more  obscured,  and  finally  disappearing  al- 
together, the  fibers  being  replaced  by  fat  granules. 

Symptoms. — The  manifestations  of  fatty  degeneration  are 
weakness  of  the  heart,  anemia  of  the  various  organs,  and  venous 
stasis.  The  cardiac  action  is  slow,  feeble,  and  irregular,  and  the 
pulse  is  compressible.  Precordial  distress  is  present,  often  aggra- 
vated by  attacks  of  angina  pectoris.  Dyspnea,  increased  on 
exertion,  is  also  a  symptom.  Anemia  of  the  brain  induces  vertigo, 
swooning,  and  pseudo-epileptic  attacks,  especially  marked  on 
suddenly  rising  from  a  recumbent  posture.  Anemia  of  the  lungs 
gives  rise  to  a  dry  hacking  cough.  Anemia  of  the  gastrointestinal 
tract  produces  dyspepsia  and  constipation.  Renal  anemia  is 
followed  by  scanty,  often  albuminous  urine  and  dropsy  begin- 
ning in  the  lower  extremities.  Weakness  and  pallor  are  common 
symptoms. 

A  formidable  symptom,  causing  much  inconvenience  as  well 
as  alarm  to  the  patient,  is  that  which  he  will  term  his  constant 
"sighing"  the  Cheyne-Stokes  breathing — "A  pause  in  the  breath- 
ing, a  complete  suspension  of  the  respiratory  acts  for  a  period  of 
time  (during  which  breathing  might  occur  several  times  in  the 
normal  manner) ,  then  the  resumption  of  respiration  very  feebly 
and  slowly,  and  a  gradual  and  progressive  increase  in  the  number 
and  depth  of  respirations  until  the  maximum  is  reached,  and 
then  again  a  gradual  and  progressive  diminution  in  the  same 
order,  in  the  number  and  depth  of  the  respirations,  until 
another   pause    occurs" — the   "oscillating  respiration." 

Concomitant  symptoms  are  atheromatous  changes  in  the 
vessels,  and  the  arcus  senilis. 

Physical  Signs. — Palpation  detects  a  weak  and  irregular  car- 
diac impulse. 

Percussion  determines  no  change  in  the  area  of  cardiac  dull- 
ness unless  cardiac  hypertrophy  is  present. 

Auscultation  reveals  a  feeble,  toneless,  almost  inaudible  first 
sound.  The  second  sound  is  normal.  Murmurs  are  not  present 
unless  there  are  coincident  valvular  lesions. 

Diagnosis. — Feeble  cardiac  sounds,  with  slow  pulse,  attacks 


PALPITATION    OF    THE   HEART.  459 

of  cardiac  asthma  or  Cheyne-Stokes  breathing,  and  evidences  of 
arcus  senilis,  make  the  diagnosis  very  certain.  The  question  of 
fibroid  heart  must  always  be  considered. 

Prognosis. — The  outlook  is  unfavorable.  Life  may  be  pro- 
longed by  appropriate  treatment  but  death  is  liable  to  occur  at 
any  time  from  cardiac  paralysis,  rupture  of  the  heart,  or 
exhaustion. 

Treatment. — There  is  no  treatment  capable  of  restoring  the 
degenerated  muscle  fibers  to  their  normal  condition.  Various 
means  may  be  employed,  however,  for  lessening  the  severity  of 
the  symptoms.  Mental  and  physical  exertion  should  be  avoided. 
The  diet  should  be  generous  and  consist  of  easily  digested  sub- 
stances. Moderate  exercise  should  be  prescribed.  Stimulants 
such  as  iron,  quinin,  strychnin,  cod-liver  oil.  and  hypophos- 
phites  should  be  administered  over  an  indefinite  period  to 
strengthen  and  maintain  the  body  tone.  All  the  secretions 
should  be  kept  active  to  relieve  the  crippled  heart  from  any 
unnecessary  strain.  The  recumbent  posture  should  be  assumed 
for  several  hours  each  day.  The  Nauheim  treatment  is  applica- 
ble. The  heart's  action  is  best  sustained  by  strychnin  sulphate, 
gr.  1/48  to  1/32  (0.0015  to  0.002  gm.),  three  or  four  times  daily, 
but  cafifein,  spartein,  and  nux  vomica  may  also  be  employed. 
Digitalis  is  contraindicated  in  advanced  cases.  For  syncopal 
attacks,  nitroglycerin,  spirit  of  nitrous  ether,  aromatic  spirit 
of  ammonia,  and  hypodermic  injections  of  ether,  camphor,  or 
whiskey  are  indicated. 


FUNCTIONAL  AFFECTIONS  OF  THE  HEART. 
PALPITATION  OF  THE  HEART. 

Synonym. — Irritable  heart. 

Definition. — A  functional  disturbance  of  the  heart;  character- 
ized by  increasing  frequency  of  its  movements  and  more  or  less 
irregularity  of  the  rhythm,  with  a  strong  tendency  toward 
hypertrophy. 


460  PALPITATION    OP    THE   HEART. 

Causes. — Among  the  more  important  causes  may  be  men- 
tioned female  sex,  puberty,  menstrual  disorders,  anemia, 
emotion,  mental  anxiety,  hysteria,  overexertion  following  acute 
or  chronic  disease,  "heart-strain"  (Da  Costa),  dyspepsia,  long- 
continued  use  of  tea,  coffee,  tobacco,  and  alcohol  in  large 
quantities,  and  excessive  venery. 

Symptoms. — Usually  palpitation  of  the  heart  has  a  sudden 
onset  after  some  one  of  the  causes  mentioned,  with  precordial 
oppression  or  pain ;  rapid,  tumultuous  beating,  the  impulse 
being  visible  through  the  patient's  clothing;  dyspnea,  anxiety, 
and  a  sense  of  choking  or  fullness  in  the  throat,  the  recumbent 
position  being  impossible;  vertigo,  faintness,  flashes  of  light, 
the  pulse  full  and  strong  or  feeble,  and  the  face  flushed  or  pale, 
the  patient  having  a  feeling  of  anxiety  with  a  sense  of  impend- 
ing danger  and  a  fear  of  sudden  death.  These  attacks  are 
paroxysmal,  lasting  from  a  few  moments  to  several  hours  or  a 
day,  the  patient  often  voiding  a  large  quantity  of  limpid  urine 
after  the  paroxysm  has  subsided,  when  there  is  a  strong  tendency 
to  sleep. 

Diagnosis. — Irritability  of  the  heart  is  differentiated  from  the 
various  forms  of  cardiac  disease  by  the  absence  of  all  the  physi- 
cal signs  mentioned  as  occurring  in  those  conditions. 

Prognosis. — If  early  and  properly  treated,  favorable. 

Treatment. — The  first  point  in  the  treatment  of  irritability  of 
the  heart  is  to  remove  the  cause;  the  next,  to  prevent  the  recur- 
rence of  the  attacks  of  palpitation. 

The  majority  of  cases  do  well  after  a  few  doses  of  either  com- 
pound spirits  of  ether  (Hoffmann's  anodyne)  or  aromatic  spirit 
of  ammonia,  or  a. combination  of  digitalis  and  belladonna.  Per- 
manent relief  is  often  afforded  by  a  combination  of  potassium 
bromid  and  veratrum  viride.  Trional,  gr.  x  to  xv  (0.6  to  i 
gm.),  three  times  daily,  is  often  useful.  If  the  patient  be  ane- 
mic, excellent  results  follow  the  prolonged  use  of  the  elixir  of 
iron,  quinin,  and  strychnin.  Locally,  belladonna  plaster  to 
the  precordium  affords  relief.  The  acute  attack  is  often  wonder- 
fully benefited  by  ice  over  the  precordium. 


TACHYCARDIA.  46 1 

TACHYCARDIA. 

Synonyms. — Rapid  heart;  quick  heart;  paroxysmal  rapid 
heart. 

Definition. — Paroxysmal  rapid  cardiac  action  with  or  with- 
out subjective  symptoms. 

Causes. — The  direct  cause  is  somewhat  obscure.  The  condi- 
tion may  be  found  associated  with  one  of  the  crises  of  cerebral  or 
spinal  disease,  the  menopause,  neuritis  of  the  pneumogastric 
nerve,  chronic  myocarditis,  neurasthenia,  chronic  gastritis, 
the  excessive  use  of  tobacco,  petit  mal,  pyrexia,  lesions  of  the 
base  of  the  brain,  etc. 

Pathology. — The  affection  has  no  structural  lesions  peculiar 
to  itself.  There  may  be  paralysis  of  the  inhibitory  fibers  of  the 
vagus,  a  direct  irritation  of  the  accelerators  of  the  sympathetic, 
or  reflex  irritation  from  some  lesion  in  the  cardiac  wall  or  else- 
where in  the  body. 

Symptoms. — The  paroxysm  is  sudden  in  its  onset,  with  or 
without  "warnings" — if  these  latter  occur,  they  are  in  the  shape 
of  vertigo,  ringing  in  the  ears,  and  a  sense  of  impending  danger. 
The  cardiac  action  is  increased  to  150,  175,  200,  rarely  250  beats 
per  minute.  The  pulse  is  small,  weak,  easily  compressible,  and 
often  irregular,  with  carotid  pulsation  (which  indicates  empti- 
ness and  low  tension  of  the  artery,  as  in  aortic  regurgitation). 
The  respiration  is  slightly  increased;  rarely  there  is  dyspnea. 
The  surface  is  at  first  pale,  but  soon  becomes  flushed.  The  ex- 
pression is  anxious  and  denotes  suffering.  There  is  a  feeling  of 
precordial  constriction,  with  more  or  less  smothering.  Rarely, 
subjective  symptoms  are  absent. 

The  duration  is  from  a  few  minutes  to  hours  or  days.  The 
attack  usually  ceases  during  sleep,  but  the  rapidity  of  the  ptdse 
may  continue  during  the  disturbed  sleep. 

Auscultation  detects  a  clear  and  ringing  first  sound,  the  strong 
and  booming  character  being  absent.  The  secon'd  sound  is 
weak  and  lacks  the  valvular  quality  of  the  normal.  A  murmur 
is   often  heard  at  the  apex. 

Diagnosis. — The  principal  points  in  distinguishing  tachycar- 


462  .  BRADYCARDIA. 

dia  from  other  cardiac  affections  are  the  paroxysmal  character, 
and  the  great  increase  in  the  pulse  rate  and  cardiac  action  of 
which  the  patient  may  or  may  not  be  conscious. 

Prognosis. — When  occurring  as  a  pure  neurosis  or  as  the 
result  of  some  cause  that  permits  of  easy  removal,  the  prognosis 
is  good.  It  is  often,  however,  an  unfavorable  symptom  of 
some  central  lesion.  When  it  develops  in  persons  suffering 
from  chronic  myocarditis  or  atheroma  of  the  vessels,  it  is  liable 
to  terminate  suddenly  in  death. 

Treatment. — As  in  other  affections  involving  the  cardiac  func- 
tions, rest  in  bed  is  of  great  importance  in  the  treatment.  The 
application  of  ice  to  the  precordium,  together  with  the  hypo- 
dermic injection  of  morphin  sulphate,  gr.  1/6  (o.oii  gm.),  and 
atropin  sulphate,  gr.  i/ioo  (0.00065  gi^-)>  ^re  of  great  benefit 
during  the  paroxysm.  Occasionally,  the  administration  of  a 
few  large  doses  of  digitalis  brings  about  the  restoration  of  car- 
diac equilibrium.  Sedatives  such  as  tincture  of  belladonna,  the 
bromids,  camphor,  trional,  etc.,  are  at  times  valuable  in  arrest- 
ing the  attacks.  During  the  intervals  between  the  paroxysms, 
the  habits  should  be  regulated  and  harmful  substances,  such  as 
alcohol,  tobacco,  tea,  and  coffee  should  be  interdicted. 

BRADYCARDIA. 

Synonym.— Brachycardia. 

Definition. — A  paroxysmal  or  permanent  slowness  in  the 
cardiac  action.  It  is  agreed  that  bradycardia  begins  when  the 
pulse  is  reduced  to  at  least  40  beats  per  minute. 

Causes. — It  is  often  associated  with  organic  nervous  diseases 
and  is  a  symptom  of  such  cardiac  diseases  as  fibroid  and  fatty 
heart  and  atheroma  of  the  coronary  arteries. 

The  condition  frequently  occurs  during  convalescence  from 
infectious  diseases,  such  as  diphtheria,  pneumonia,  typhoid 
fever,  erysipelas,  and  rheumatism;  uremia,  lead-poisoning, 
anemia,  and  chronic  alcoholism  are  often  causes.  According 
to  Balfour,  "  Many,  if  not  most,  of  the  sufferers  from  brady- 
cardia are  epileptics." 


ARRHYTHMIA.  463 

Symptoms. — The  slow  action  of  the  heart,  varying  from 
40  to  8  beats  per  minute,  is  the  most  prominent  manifestation. 
The  pulse  is  weak,  small,  and  slow.  The  first  sound  of  the 
heart  is  soft  and  feeble  and  often  the  second  sound  is  inaudible. 
As  a  result  of  the  slow  cardiac  action  there  are  noises  in  the 
ears,  vertigo,  syncopal  attacks,  and  rarely  convulsions.  Pre- 
monitory signs  may  or  may  not  be  present. 

Prognosis.- — The  outlook  depends  entirely  upon  the  cause. 
When  due  to  grave  organic  disease,  sudden  death  is  not  an 
uncommon  termination. 

Treatm.ent. — As  long  as  the  slow  cardiac  pulsations  are 
sufficient  to  supply  the  requirements  of  the  economy,  medica- 
tion is  not  needed;  when,  however,  the  reverse  obtains,  rest  in 
the  recumbent  position,  heat  to  the  precordium,  and  the  use  of 
such  remedies  as  atropin  sulphate,  citrated  caffein,  strychnin 
sulphate,  spirit  of  glonoin,  and  aromatic  spirit  of  ammonia 
are  indicated.  Often  the  emergency  is  so  great  as  to  call  for 
the  hypodermic  use  of  the  selected  drug. 

Digitalis  is  contraindicated.  Between  the  paroxysms,  such 
remedies  as  improve  the  general  health  and  prevent  the  prog- 
ress of  the  central  or  exciting  cause  are  required. 


ARRHYTHMIA. 

Synonyms. — Arrhythmia  cordis;  irregularity  of  the  pulse. 

Definition. — A  lack  of  cardiac  rhythm,  or  irregularity  in  the 
cardiac  pulsations.      It  is  a  symptom  rather  than  a  disease. 

Causes. — Valvular  diseases;  myocardial  diseases;  cardiac 
dilated  hypertrophy;  atheroma  of  coronary  arteries  and  aorta; 
excessive  use  of  tobacco,  tea,  or  coffee;  flatulent  dyspepsia; 
neurasthenia,  hysteria,  and  melancholia. 

Symptoms. — An  irregularity  in  cardiac  action,  either  in  the 
rhythm  or  the  regularity  of  the  force  of  the  beats,  or  an  inter- 
mission in  the  cardiac  contractions.  Symptoms  referable  to 
the  underlying  cause  are  also  present. 

Diagnosis. — An    examination    of    the    pulse,    ausculation    of 


464  ANGINA   PECTORIS. 

the  heart,  and  the  use  of  the  sphygmograph  determine  the 
arrhythmia. 

Prognosis. — Depends  upon  the  cause.  In  functional  cases 
favorable,  in  organic  cases  unfavorable. 

Treatm.ent. — In  purely  functional  conditions  rest  of  mind 
and  body  with  regulation  of  the  diet,  attention  to  the  secretions, 
and  the  administration  of  the  bromids  are  of  great  value.  In 
other  cases,  strychnin  or  digitalis  in  addition  to  treatment 
directed  toward  the  underlying  cause  is  indicated. 


ANGINA  PECTORIS. 

Synonyms. — Neuralgia  of  the  heart;  stenocardia;  breast-pang. 

Definition. — Paroxysms  in  which  there  occur  sharp  cardiac 
pains,  extending  usually  into  the  left  shoulder  and  down  the 
left  arm,  accompanied  by  a  feeling  of  constriction  of  the  thorax 
and  a  strong  fear  of  impending  death. 

Causes. — The  direct  cause  of  the  affection  is  insufficient 
nutrition  of  the  heart.  This  deficiency  may  be  brought  about 
by  disease  or  obstruction  of  the  coronary  arteries,  diseased 
conditions  of  the  aortic  valve,  pressure  of  an  adjacent  tumor, 
excessive  dilatation  or  enlargement  of  the  heart,  adhesive 
pericarditis,  habitual  use  of  tobacco,  etc.  The  tendency  may 
be  inherited.  Syphilis  and  hysteria  may  exert  an  influence  in 
its  production.  According  to  Trousseau  it  may  be  considered 
as  a  form  of  masked  epilepsy  or  it  may  alternate  with  true 
epileptic  attacks.  AUbutt  believes  it  to  be  due  to  an  acute 
aortitis.  Male  adults  after  forty  years 'of  age  are  most  often 
affected  and  the  attacks  are  precipitated  by  overexertion, 
great  mental  excitement,  or  acute  indigestion. 

Pathology. — The  most  constant  structural  changes  are 
sclerosis,  atheroma,  and  obliteration  of  the  coronary  arteries. 
Such  changes  may  be  present  without  angina  and,  on  the  other 
hand,  anginoid  attacks  may  occur  independent  of  structural 
alterations.  Functional  disturbances  of  the  cardiac  plexuses 
are  responsible  for  the  symptoms. 


ANGINA    PECTORIS.  465 

Symptoms. — The  chief  symptom  is  intense  agonizing  pain 
which  begins  in  the  region  of  the  heart  and  extends  to  the  neck 
and  down  the  left  arm.  Shortness  of  breath,  and  precordial 
oppression  are  present.  The  chest  is  fixed  and  the  heart's 
action  is  weak  and  feeble.  The  face  is  pale  or  ashen  gray,  the 
expression  is  anxious,  and  there  is  a  fearful  sense  of  impending 
death.  The  body  and  face  are  covered  with  drops  of  cold 
sweat.  The  pain  usually  lasts  but  a  few  seconds  or  minutes. 
Extreme  prostration  follows  the  attack  unless  it  is  terminated 
meanwhile  by  death.  The  end  of  the  paroxysm  is  marked  by 
cessation  of  the  pain  and  precordial  distress,  and  by  vomiting, 
or  excessive  flow  of  urine.  The  first  attack  may  end  in  death 
or  there  may  be  a  recurrence  at  varying  periods,  sometimes 
extending  over  years. 

The  unpleasant  sensations  of  these  patients  during  an  attack, 
and  the  nervous  disorder  associated  with  it,  slowly  bring  about 
a  mental  change.  They  are  depressed  and  gloomy,  sometimes 
suicidal,  and  often  develop  epilepsy. 

•  Attacks  of  angina  in  nervous  women  and  children,  the  hysteric 
or  pseudoanginal  attacks,  come  on  gradually  with  distention  of 
the  abdomen,  eructations  of  gases,  excessive  restlessness, 
flushed  face,  irritable  pulse,  diffused  precordial  pain,  and 
general  hysteric  phenomena. 

In  a  few  cases  the  pain  is  absent,  but  all  other  symptoms  are 
present — the  ''angina  sine  dolore"  of  Gairdner.  Balfour 
claims  that  pain  is  not  an  essential  part  of  the  disease. 

Diagnosis. — The  points  to  be  remembered  are  that  the 
attacks  are  always  paroxysmal,  with  long  or  short  intervals, 
the  patient  having  a  sense  of  coldness,  and  frequently  a  cold 
sweat,  the  heart's  action  being  not  increased,  the  chest  fixed, 
and  the  breathing  slow. 

Intercostal  neuralgia  and  gastralgia  may  be  confused  with 
this  affection,  but  the  history  and  concomitant  symptoms  of 
the  former  conditions  will  aid  greatly  in  making  a  diagnosis. 
These  affections  lack  the  characteristic  paroxysms  observed  in 
true  angina  pectoris. 

Pseudoangina  is  well  differentiated  in  Huchard's  table: 
30 


466  ANGINA    PECTORIS. 


True  Angina.  Pseudo-angina. 

Most  common  past  middle  life At  every  age  from  six  years. 

Most  common  in  men Most  common  in  females. 

Attacks — rarely  nocturnal  or   peri-  Often  periodical  and  nocturnal. 

odical. 

Not  associated  with  other  symptoms.  Associated  with  nervous  symp- 
toms. 

Agonizing   pain    and   sense   of   con-  Pain     less      severe — distention 

striction.  more  than  constriction. 

Pain  of  short  duration Pain  lasts  one  or  two  hours. 

Lesions  of  arterial  sclerosis :  .  .  Neuralgic  affection. 

Prognosis  grave;  often  fatal Never  fatal. 

Prognosis.- — The  otitlook  in  true  angina  pectoris  is  -unfavorable. 
Seventy-five  per  cent  recover  from  the  first  attack  but  the  affec- 
tion ultimately  terminates  fatally.  In  pseudo-angina  the  prog- 
nosis is  always  favorable. 

Treatment. — The  Attack:  Prompt  relief  follows  the  immediate 
inhalation  of  amyl  nitrite,  niiii  to  v  (0.2  to  0.3  c.c),  or  chloro- 
form, or  the  hypodermic  injection  of  morphin  sulphate,  gr.  1/4 
(0.016  gm.),  combined  with  atropin  sulphate,  gr.  i/ioo  (0.00065 
gm.),  or  nitroglycerin,  gr.  i/ioo  to  1/50  (0.00065  "to  0.0013  gm.). 
In  many  cases,  the  use  of  nitroglycerin,  gr.  i/ioo  (0.00065  gi^-)> 
three  times  daily,  over  an  extended  period,  lessens  not  only 
the  frequency  but  also  the  severity  of  the  paroxysm.  Chloro- 
dyne,  ir^x  to  xv  (0.6  to  i  c.c),  repeated  often  affords  relief. 
Spartein  sulphate,  gr.  1/4  (0.016  gm.),  three  times  daily,  is 
also  highly  recommended.  The  application  of  a  mustard 
plaster  or  other  form  of  counterirritation  to  the  precordium  is 
productive  of  considerable  benefit. 

The  Interval:  Attempts  should  be  made  to  remove  the  exciting 
causes  or  to  diminish  their  influence.  Great  care  should  be 
exercised  in  the  diet  that  flatulency  and  constipation  do  not 
occur.  Mental  excitement  and  physical  exertion  should  be 
avoided.  When  structural  changes  are  suspected,  potassium 
iodid,  gr.  x  to  xx  (0.6  to  1.3  gm.),  three  times  daily,  should  be 


ARTERIOSCLEROSIS.  467 

administered.  The  nitrites,  and  nitroglycerin  should  be 
employed  as  they  lessen  materially  the  frequency  and  severity 
of  the  paroxysms.  Tonics  such  as  iron,  arsenic,  strychnin, 
phosphorus,  etc.,  are  of  value  in  that  they  increase  the  resistance 
of  the  body  and  improve  its  general  tone.  Strophanthus  and 
strychnin  are  indicated  when  the  heart  is  weak.  Trousseau 
advises  the  long-continued  administration  of  small  doses  of 
belladonna.  Quain  employs  the  constant  current,  applying 
the  positive  pole  over  the  sternum  and  the  negative  pole  over 
the  lower  vertebrae.  The  Nauheim  treatment,  particularly  the 
hot  baths,  may  be  of  benefit.  The  cold  batiis  are  positively  harm- 
ful in  this  condition. 

Pseudo-angina  requires  the  treatment  prescribed  for  hysteria 
in  general. 

DISEASES  OF  THE  ARTERIES. 

ARTERIOSCLEROSIS. 

Synonyms. — Atheroma;  arteriocapillary  fibrosis;  endarteritis 
chronica  deformans. 

Definition. — A  chronic  degenerative  and  inflammatory  disease 
of  the  vascular  system,  resulting  in  an  overgrowth  of  the  con- 
nective tissues  of  the  arteries,  followed  by  calcareous  deposits. 
The  changes  may  extend  to  the  capillaries  and  veins.  As  a 
result  of  the  impairment  of  the  arterial  circulation,  there  occur 
fibroid  degenerations  in  other  organs,  resulting  in  loss  of  elas- 
ticity in  the  walls  of  the  vessels,  increase  of  arterial  tension, 
narrowing  of  the  caliber  of  smaller  arteries,  and  impairment 
of  the  nutrition  of  the  organs  supplied. 

Causes. — The  principal  etiologic  factors  are  senility,  heredity, 
male  sex,  alcoholism,  syphilis,  lead-poisoning,  diabetes,  malaria, 
gout,  rheumatism,  lithemia,  Bright's  disease,  exposure,  and  ex- 
cesses of  various  kinds.  The  condition  of  the  arteriocapillary 
system  may  be  taken  as  an  index  of  an  individual's  age.  The 
main  factors  are  "time,  tension,  and  toxins."  i    | 

Pathologic  Anatomy. — The  atheromatous  changes  are  most 


468  ARTERIOSCLEROSIS. 

frequent  in  the  aorta.  Rokitansky  gives  the  relative  order  in 
which  atheromatous  degenerations  occur  as  follows:  aorta, 
splenic,  femoral,  iliac,  coronary  arteries  of  the  heart,  arteries  of 
the  brain,  uterine,  subclavian,  brachial,  ulnar,  and  radial  arteries. 

The  internal  surface  of  the  affected  vessels  is  irregularly 
thickened  with  gelatinous  and  translucent,  dense  and  fibrous, 
or  calcareous  deposits.  If  the  calcification  is  extensive,  the 
vessel  is  changed  into  a  hard,  stiff  tube.  Often  the  surface  of 
the  thickening  or  deposit  is  destroyed,  presenting  the  so-called 
"atheromatous  ulcers,"  which  may  be  covered  with  masses  of 
thrombi. 

The  above  conditions  are  the  result  of  inflammatory  change 
in  the  intima  of  the  affected  vessel  which  appears  three  or  four 
times  as  thick  as  normal,  due  to  the  swelling  of  its  elements,  the 
new  growth  of  connective  tissue,  and  the  deposit  of  round  cells. 
Fatty  degeneration  of  the  inflammatory  products  is  the  common 
sequence. 

The  result  of  the  changes  in  the  arteries  is  a  loss  of  elasticity, 
thus  hindering  the  propulsion  of  the  blood  current  and  raising 
the  arterial  tension,  ultimately  leading  to  hypertrophy  of  the  left 
ventricle.  These  changes  finally  involve  the  coronary  arteries 
and  lead  to  alterations  in  the  myocardium.  The  nutrition  of 
various  other  organs  is  likewise  impaired  when  the  intima  of 
their  respective  arteries  is  involved  in  the  degenerative  process. 

Symptoms. — These  are  not  always  apparent  and  vary  with 
the  arteries  involved  and  their  distribution.  When  the  process 
is  general,  the  peripheral  arteries  have  a  hard  bony  feel,  not  un- 
like whip-cord.  The  increased  resistance  of  the  arterial  system 
induces  increased  cardiac  activity  and  consequent  hypertrophy. 

Attacks  of  vertigo,  pseudo-apoplectic  attacks,  or  spells  of  unr 
consciousness  in  the  aged  or  those  having  superficial  hardened 
arteries,  are  generally  due  to  changes  in  the  cerebral  vessels. 
Evidences  of  myocarditis  and  angina  pectoris  point  to  atheroma 
of  the  aorta  and  coronary  arteries.  Renal  arteriosclerosis 
manifests  itself  as  chronic  interstitial  nephritis.  Gangrene  of 
the  extremities  in  the  old — senile  gangrene — point  to  ather- 
oma or  thrombi,  the  result  of  the  fibrosis. 


ANEURYSM   OF    THE   AORTA.  469 

Physical  Signs. — Palpation  reveals  a  forcible  cardiac  impulse 
in  the  early  stages.  The  superficial  arteries  are  hard  and  those 
at  the  wrists  feel  like  a  string  of  beads  pulsating. 

Percussion  shows  increased  precordial  dullness  especially  over 
the  left  ventricle. 

Auscultation  in  the  early  stage  detects  prolongation  of  the  first 
sound  with  the  accentuation  of  the  second  sound  over  the  aortic 
cartilage.  As  the  heart  dilates  and  the  walls  become  diseased, 
the  sound  becomes  feeble  and  often  irregular  and  intermittent. 

Sequels. — As  consequences  of  this  condition  of  the  arterial 
system  may  be  mentioned  cerebral  hemorrhage,  thrombosis, 
embolism,  or  aneurysm,  myocarditis,  angina  pectoris,  chronic 
interstitial  nephritis,  gangrene,  aneurysm,  etc. 

Prognosis. — The  structural  changes  may  be  prevented  or  re- 
tarded but  cannot  be  removed. 

Treatment. — The  habits,  hygiene,  mode  of  life,  diet,  etc., 
should  be  most  carefully  regulated.  When  the  cause  or  causes 
are  detected  they  should  be  promptly  removed.  The  secretions 
should  be  kept  free  at  all  times.  Constipation  should  be  avoided 
as  it  serves  to  embarrass  the  functional  activity  of  the  liver  and 
kidneys.  Alcohol  should  be  interdicted.  Moderate  exercise 
is  of  benefit.  Potassium  iodid  and  nitroglycerin  should  be 
administered  in  small  doses  indefinitely.  Overexertion  of  any 
kind  should  be  avoided. 

ANEURYSM  OF  THE  AORTA. 

Varieties. — I.  Aneurysm  of  the  arch  of  the  aorta.  II.  An- 
eurysm of  the  thoracic  aorta.  III.  Aneurysm  of  the  abdom- 
inal aorta. 

The  arch  of  the  aorta  is  divided  into  three  parts — the  ascend- 
ing, the  transverse,  and  the  decending. 

The  ascending  portion  is  2  inches  in  length,  arising  from  the 
left  ventricle,  on  a  level  with  the  lower  border  of  the  left  third 
costal  cartilage,  behind  the  left  edge  of  the  sternum.  It  ascends 
obliquely  upward  to  the  right  to  the  upper  border  of  the  right 
second  costosternal  articulation.  The  transverse  portion  com- 
mences at  the  upper  border  of  the  right  second  sternal  articula- 


470  ANEURYSM^OF    THE   ARCH    OF    THE   AORTA. 

tion,  and,  arching  to  the  left  and  forward,  passes  in  front  of  the 
trachea  and  esophagus  to  the  left  of  the  third  dorsal  vertebra. 
The  descending  portion  extends  downward  to  the  left  side  of 
the  fourth  dorsal  vertebra. 

The  thoracic  aorta  extends  from  the  left  lower  border  of  the 
fourth  dorsal  vertebra,  and  ends  in  front  of  the  body  of  the 
twelfth  dorsal  vertebra,  at  the  aortic  opening  in  the  diaphragm. 

The  abdominal  aorta  begins  at  the  aortic  opening  in  the  dia- 
phragm, descends  a  little  to  the  left,  side  of  the  vertebral 
column,  and  terminates  over  the  body  of  the  fourth  lumbar 
vertebra,  where  it  divides  into  the  two  iliac   arteries. 

Definition. — A  circumscribed  dilatation  of  some  portion  of 
the  aorta,  the  result  of  disease  of  the  vessel  wall  weakening  its 
resistance  to  the  blood  pressure. 

Causes. — Conditions  that  induce  arteriosclerosis  are  the  chief 
causes.  Exertion  is  an  exciting  cause.  Aneurysms  occur  in  early 
middle  life  rather  than  in  old  age,  when  the  force  of  the  heart 
has  decreased.     They  are  more  common  in  men  than  in  women. 

Pathologic  Anatomy. — All  aneurysms  may  be  divided  into 
two  classes,  dissecting  and  circumscribed.  Dissecting  aneurysms 
occur  in  the  aged  and  result  from  fatty  changes  in  the  internal 
and  middle  coats.  The  intima  usually  ruptures  allowing  the 
blood  to  dissect  its  way  between  the  coats  of  the  vessel.  Cir- 
cumscribed aneurysm  is  most  common  in  middle-aged  men 
and  can  usually  be  ascribed  to  syphilis.  It  consists  of  a  circum^- 
scribed  dilatation  of  the  affected  vessel.  It  may  he  fusiform, 
sacculated,  or  cylindric  in  shape.  A  true  aneurysm  is  one  in 
which  the  dilatation  is  confined  to  the  vessel  wall ;  a  false  an- 
eurysm is  one  in  which  the  vessel  wall  has  ruptured  and  the 
extravasated  blood  has  become  encapsulated  by  the  adjacent 
connective  tissue. 

ANEURYSM  OF  THE  ARCH  OF  THE  AORTA. 

Etiology. — In  addition  to  the  general  causes,  given  alone, 
there  are  many  reasons  given  why  aneurysm  should  be  so 
common  in  the  arch  of  the  aorta,  viz.: — The  arch  of  the  aorta  is 


ANEURYSM  OF  THE  ARCH  OF  THE  AORTA.         47 1 

very  curved,  the  first  part  of  the  arch  has  but  little  support, 
the  force  of  the  blood  current  tends  to  bulge  the  aorta  locally, 
in  this  part  large  branches  are  given  off  in  a  very  small  area; 
cardiac  pressure  shows  greater  variations  here  than  in  parts 
further  away. 

Symptoms. — This  variety  of  aneurysm  is  the  most  common. 
The  onset  is  usually  gradual,  with  evidences  of  arteriosclerosis 
and  failing  health.  Pain,  which  may  be  paroxysmal  or  contin- 
uous, is  a  constant  symptom.  Dyspnea  is  also  common  and 
may  be  constant  with  acute  exacerbations,  or  may  be  remittent. 
Occasionally,  dysphagia  occurs.  A  slight  cough  from  pressure 
on  the  recurrent  laryngeal  nerve,  with  more  or  less  alterations 
in  the  voice,  may  be  present.  The  pupils  are  dilated  or 
contracted,  or  are  irregular  in  some  cases,  due  to  pressure 
on  the  sympathetic  nerve.  There  are  disorders  of  the  circu- 
lation, a  gradual  loss  of  flesh,  and  a  careworn  expression  of 
the  face. 

Physical  Signs. — Inspection  is  negative  until  the  tumor  be- 
comes large  when  circumscribed  bulging  and  abnormal  pulsation 
may  be  noticed. 

Palpation  detects  expansile  pulsation  (Corrigan's  sign)  which 
is  characteristic.  Tenderness  may  be  present  over  the  aneu- 
rysm. A  thrill  may  be  detected.  Diastolic  shock  due  to  the 
recoil  of  the  blood  in  the  aneurysm  on  the  closed  aortic  valve 
may  also  be  recognized. 

Tracheal  tugging  is  often  present  and  is  diagnostic.  To  obtain 
it,  the  patient  should  be  placed  in  the  erect  position,  with  his 
mouth  closed  and  chin  elevated  to  the  greatest  extent.  The 
cricoid  cartilage  should  then  be  grasped  between  the  fingers  and 
thumb  and  gentle  traction  upward  should  be  made.  The 
pulsations  of  the  dilated  aorta  or  aneurysm,  if  any  exist,  will 
then  be  distinctly  felt,  in  most  cases  transmitted  through  the 
trachea  to  the  hand.  Aneurysm  of  the  arch  also  gives  rise  to 
alteration  in  the  radial  pulse.  When  the  aneurysm  is  situated 
at  the  transverse  portion  of  the  arch,  the  left  radial  pulse  and 
the  left  carotid  pulse  are  smaller  and  weaker  than  those  on  the 
right  side. 


472 


ANEURYSM  OF  THE  ARCH  OF  THE  AORTA. 


Ascending. 


Descending. 


Physical  signs. 


Pulsation,  often  ex- 
pansile, in  second 
and  third  interspaces 

On  palpation  systolic 
thrill  and  diastolic 
shock  to  right  of 
sternum. 

Dullness  to  right  of 
sternum,  above  car- 
diac area. 

Rough  systolic  mur- 
mur, loud  clanging 
second  sound.  May 
have  diastolic  mur- 
mur from  implica- 
tion of  aortic  valve. 


Pulsation  in  episternal 
notch. 

Systolic    thrill  in  epi- 
sternal notch. 


Dullness  over  man- 
ubrium stemi. 

Murmur  more  distinct; 
over  manubrium  j 
Diastolic  murmurj 
rare. 


Pulsation,   if  any,   to 
left  of  spine. 

Absent. 


No  dullness  anteriorly, 
sometimes  dull  to 
left  of  spine. 

Murmur  may  be 
absent ;  when  pres- 
ent systolic,  to  left 
of  spine. 


Parts  liable  to 
pressure  and 
results  of  pres- 
sure. 


Vena  cava  superior ; 
dilated  superficial 
veins,  edema  of 
head  and  neck. 

Innominate  artery ; 
weakness  of  right 
radial  pulse.  | 

i 
Heart;    downwardi 
displacement  of 

apex. 
Ribs  to  right  of  ster- 
num; pain. 


Right  bronchus ;  de- 
fective respiration 
on  right  side. 


Right  recurrent  laryn- 
geal (rarely) ;  paraly- 
sis of  right  vocal 
cord. 


Left  innominate  vein; 
edema  of  left  side  of 
head  and  neck. 


Any  branch  of  the 
arch ;  weakness  of 
right  or  left  radial 
pulse. 


Manubrium 
pain. 


stemi ; 


Trachea  or  left 
bronchus;  paroxys- 
mal dyspnea,  al- 
tered cough  defec- 
tive respiration  on 
left  side. 

Left  recurrent  laryn- 
geal ;  paralysis  of 
left  vocal  cord. 

Sympathetic ;  dilata- 
tion or  contraction 
of  pupil,  usually  left  ' 


Esophagus ; 
phagia. 


dys- 


Spinal  column,  and 
ultimately  cord ; 

dorsal  pain,  after- 
wards paraplegia. 

Left  bronchus;  defec- 
tive respiration  on 
left  side. 


Left  recurrent  laryn- 
geal; paralysis  of 
left  vocal  cord. 

Left  sympathetic 
(often) ;  dilatation  or 
contraction  of  left 
pupil. 

Esophagus ;  dys- 

phagia. 

Thoracic  duct;  rapid 
emaciation  some- 
times chylous  as- 
cites. 


or     other 


Rupture        may    Externally ,  i  Into  trachea . 

occur.  Into  pericardium I  Into     one 

I  j      pleura. 

Into  right  pleura  .  .  .  .  '  Into  left  innominate. 
Into  right  bronchus,    j 
Into  superior  cava. 


Into  left  bronchus. 
Into  left  pleura. 

Into  esophagus. 


ANEURYSM    OF    THE  ABDOMINAL   AORTA.  473 

Perctission  yields  an  abnormal  area  of  dullness  with  increased 
resistance. 

Auscultation  serves  to  elicit  a  murmur  or  bruit  over  the  tumor 
synchronous  with  the  first  sound  of  the  heart.  It  is  louder  than 
the  systole,  lower  in  pitch,  and  of  a  blowing  character.  When 
the  aortic  valves  are  intact,  the  second  aortic  sound  will  be 
markedly  accentuated. 

Diagnosis. — The  presence  of  a  tumor,  as  shown  by  the 
abnormal  area  of  dullness,  with  expansile  pulsation  and  a  bruit 
in  the  region  occupied  by  the  aortic  arch,  is  diagnostic.  The 
%-TSiy  will  serve  to  define  its  exact  situation  and  outlines.  The 
signs  and  symptoms  will  vary  according  to  the  part  of  the  arch 
involved.  This  is  well  shown  in  the  table  on  page  472,  from 
Wheeler  and  Jack: 

ANEURYSM  OF  THE  THORACIC  AORTA. 

Symptoms. — The  most  constant  symptom  is  deep-seated 
thoracic  pain,  constant  or  paroxysmal.  Dysphagia  is  a  fre- 
quent condition.  There  is  seldom  dyspnea,  and  alteration  of 
voice  and  pupils  does  not  occur.     Death  may  occur  suddenly. 

Physical  signs  are  seldom  distinctive  and  the  diagnosis  is 
rarely  made  during  life. 

ANEURYSM  OF  THE  ABDOMINAL  AORTA. 

Symptoms. — The  most  constant  symptom  is  pain  situated  in 
some  area  corresponding  to  the  aneurysm,  or  widely  diffused 
over  the  abdomen.  Gastrointestinal  symptoms  appear  and  the 
general  health  fails.  The  pressure  of  the  tumor  induces 
retardation  of  the  femoral  pulse.  Other  pressure  symptoms 
depend  on  the  location  of  the  aneurysm.  In  most  cases,  it  is 
situated  near  the  celiac  axis. 

The  physical  signs  reveal  abnormal  dullness,  and  the  presence 
of  a  tumor  with  expansile  pulsation  and  a  bruit  to  the  left  of 
the  median  line  of  the  abdomen. 


474  Aneurysm  of  the  abdominal  aorta. 

Diagnosis. — Pulsating  abdominal  aorta  may  be  distinguished 
from  abdominal  aneurysm  by  its  occurrence  in  paroxysms,  in 
nervous  women  and  effeminate  men,  and  by  the  absence  of  a 
tumor,  expansile  pulsation,  and  pressure  symptoms. 

Abdominal  tumors  resting  on  the  aorta  may  transmit  its 
pulsation.  The  assumption  of  the  knee-chest  posture  causes 
the  tumor  to  fall  away  and  the  pulsation  is  lost. 

Prognosis  of  Aortic  Aneurysm. — Unfavorable.  The  duration 
of  life  after  the  development  of  the  aneurysm  is  from  one  to 
four  years.  The  termination  may  be  sudden  from  rupture  and 
hemorrhage,  or  gradual  from  exhaustion. 

Treatment. — The  object  of  the  treatment  is  to  promote 
coagulation  of  the  blood  within  the  sac  and  to  bring  about  con- 
traction of  the  tumor,  at  the  same  time  being  careful  to  avoid 
violent  rupture. 

The  so-called  Tufnell's  method  is  the  most  successful  for  these 
purposes,  its  aim  being  to  diminish  the  force  and  rapidity  of  the 
circulation,  and,  if  possible,  to  increase  the  fibrinous  deposit. 
Its  essential  element  is  absolute  rest  of  mind  and  body,  and  a 
restricted  diet;  the  patient  is  kept  absolutely  in  bed  day  and 
night  for  at  least  three  months,  and  placed  on  the  following 
diet:  Breakfast — 2  ounces  of  bread  with  butter  and  2  ounces  of 
milk;  dinner — 2  or  3  ounces  of  bread,  same  amount  of  meat, 
and  2  to  4  ounces  of  milk  or  claret  wine;  supper — 2  ounces  of 
bread  with  butter  and  2  ounces  of  milk.  At  the  same  time 
potassium  iodid  is  administered  in  increasing  doses  to  the 
physiologic  limit. 

Galvanopuncture  is  said  to  do  good  in  some  cases;  two 
needles  inserted  into  the  aneurysm  are  connected  with  the  poles 
of  a  galvanic  battery,  and  a  weak  current  is  passed  through  the 
tumor.  Various  surgical  procedures  have  been  employed, 
from  time  to  time,  but  the  success  following  them  is  doubtful. 

The  severe  pain  indicates  the  use  of  morphin  and  the  local 
application  of  an  ice-bag.  Cyanosis  and  dyspnea  will  be 
relieved  to  some  extent  by  venesection. 


PHYSICAL    DIAGNOSIS.  475 

DISEASES  OF    J  HE  RESPIRATORY  SYS  lEM. 
PHYSICAL  DIAGNOSIS. 

Physical  diagnosis  is  the  art  of  discriminating  disease  by 
means  of  the  eye,  the  ear,  and  the  touch. 

The  signs  thus  ascertained  are  connected  with  changes  or 
alterations  in  the  form,  density,  or  condition  of  the  structures 
within,  and  are  known  as  physical  signs. 

"  Physical  signs  are,  then,  the  exponents  of  physical  conditions, 
and  of  nothing  more"  (Da  Costa). 

The  methods  employed  in  the  physical  exploration  of  the 
chest,  are:  I,  Inspection;  II,  Palpation;  III,  Mensuration;  IV, 
Percussion;  V,  Auscultation;  VI,  Succussion. 

Chest  Divisions. — For  the  purpose  of  physical  exploration,  the 
chest  is  mapped  off  into  regions  or  divisions,  as  follows: 

ANTERIORLY. 

1.  Siipra-davicidar,  lying  above  the  upper  edge  of  the 
clavicle,  usually  about  an  inch  in  extent.  It  contains  the  apex 
of  each  lung,  with  portions  of  the  subclavian  and  carotid  arteries 
and  the  subclavian  and  jugular  veins. 

2.  Clavictdar,  corresponding  to  the  inner  two-thirds  of  the 
clavicle. 

3.  Infra-clavicular,  from  the  clavicle  to  the  lower  border 
of  the  third  rib,  and  from  the  edge  of  the  sternum  to  a  line 
drawn  vertically  downward  from  the  junction  of  the  middle  and 
outer  third  of  the  clavicle.  This  region  contains  the  upper  lobe 
of  the  lung  and  the  main  bronchi ;  on  the  right  side  the  superior 
vena  cava  and  part  of  the  aortic  arch;  and  on  the  left  side  a 
portion  of  the  pulmonary  artery. 

4.  Mammary,  between  the  third  and  sixth  ribs.  In  the 
center  of  this  region  between  the  fourth  and  fifth  ribs  is  placed 
the  nipple.  On  the  right  side  this  region  contains  the  right  lung, 
part  of  the  diaphragm,  a  portion  of  the  right  auricle  and  right 
ventricle;  on  the  left  side,  the  lung  and  a  small  part  of  the  right 
ventricle. 


476 


PHYSICAL    DIAGNOSIS. 


Fig.  S3. — Anterior  View  of  the  Lungs,  Heart, and  Abdominal  Organs  with 
Reference  to  their  Relation  to  the  Skeleton  and  the  Outline  of  the  Stomach. 
(Tyson  s  Diagnosis.) 

I,  Larynx;  2,  thyroid  gland;  3,  trachea;  4,  right  lung  apex;  5,  upper  lobe,  6,  middle 
lobe,  7,  lower  lobe,  of  right  lung;  8,  upper,  9,  lower,  interlobular  boundary  of  the  right 
lung;  10,  apex,  11,  upper  lobe,  12,  lingual  process  of  the  left  lung;  13,  cardiac  boundary 
of  the  anterior  border  of  the  left  lung;  14,  portion  of  the  anterior  aspect  of  the  peri- 
cardium covered  by  the  cardiac  pleura;  15,  portion  of  the  same  uncovered  by  diaphragm. 
Site  for  paracentesis;  16,  anterior  border  of  the  mediastinum;  17,  anterior  border  of  the 
left  mediastinum;  18,  upper  or  true  border  of  the  liver  partially  covered  by  lung;  19, 
right  lobe  of  the  liver;  20,  quadrate  lobe  of  the  liver;  21,  left  lobe  of  the  liver;  22,  gall- 
bladder; 23,  cardiac  end  of  the  stomach;  24,  stomach  cul-de-sac  partially  covered  by 
lung;  25,  pyloric  end  of  the  stomach;  26,  larger  cxirvature  of  the  stomach  (right  gastro- 
epiploic artery);  27,  transverse  colon;  28,  ascending  colon;  29,  descending  colon;  31, 
small  intestine.     (After  Luschka,  slightly  modified.) 


PHYSICAL    DIAGNOSIS. 


477 


Fig.  54. — Posterior  View  of  the  Organs  of  the  Chest  and  Abdominal  Cavity. 

(Tyson's  Diagnosis.) 

I,  Upper  lobe,  2,  lower  lobe,  of  left  lung;  3,  interlobular  boundary  between  them ; 
4,  upper  lobe  of  right  lung;  5,  lower  lobe  of  right  lung;  6,  middle  lobe  of  the  right  lung; 
7,  line  between  upper  and  middle  lobes  of  the  right  lung;  9,  stomach  demarked  by  a 
dark  line;  10,  spleen  in  its  relation  to  the  lung  in  expiration  with  the  kidney  showing 
behind  and  below  it;  11,  left  kidney;  12,  horizontal  upper  part  of  the  duodenum;  13, 
descending  .portion  of  the  duodenum;  14,  horizontal  lower  part  of  the  duodenum; 
IS,  duodeno- jejunal  flexure;  16,  liver;  20,  pancreas;  21,  first  dorsal  vertebra.  (After 
Luschka.) 


478  PHYSICAL    DIAGNOSIS. 

5.  Infra-mammary,  downward  from  the  sixth  rib  to  the 
margin  of  the  false  ribs.  On  the  right  side  it  contains  the  Hver 
and  a  small  portion  of  the  lung  on  deep  inspiration;  on  the  left 
side,  the  left  lobe  of  the  liver,  stomach,  and  part  of  the  spleen. 

6.  The  tipper  sternal  region  extends  from  the  suprasternal 
notch  to  the  junction  of  the  third  costal  cartilage  and  sternum. 
The  ascending  arch  of  the  aorta,  portions  of  the  superior  vena 
cava,  the  innominate  veins,  subclavian  arteries,  esophagus,  and 
trachea  are  found  in  this  region. 

7.  The  lower  sternal  region  extends  downward  from  the 
junction  of  the  third  costal  cartilage  with  the  sternum,  and  con- 
tains portions  of  the  lung,  right  and  left  ventricles,  and  stomach. 

The  mammillary  line  or  nipple  line  extends  vertically  through 
the  nipple;  but  this  latter  is  far  too  variable  in  position  to  be 
taken  as  a  "  fixed  point." 

The  parasternal  line  is  a  vertical  line  placed  midway  between 
the  border  of  the  sternum  and  the  mammillary  line. 

LATERALLY. 

1.  Axillary,  that  portion  above  the  sixth  rib.  The  upper 
lobes  of  the  lung  and  the  main  bronchi  are  to  be  found  in  this 
region. 

2.  Infra- axillary,  that  portion  below  the  sixth  rib.  On  the 
right  side,  it  contains  the  lung  and  liver;  on  the  left  side,  the 
lung,  stomach,  and  spleen. 

POSTERIORLY. 

1.  Supra-scapular,  that  portion  above  the  scapula. 

2.  Scapular,  that  portion  covered  by  the  scapula.  It  con- 
tains the  greater  portion  of  the  lung. 

3.  Inter-scapular,  that  portion  between  the  scapulae.  It 
extends  from  the  second  to  the  sixth  vertebra  and  contains 
portions  of  the  lungs,  bronchi,  esophagus,  and  descending  aorta. 

4.  Infra- scapular,  that  portion  below  the  angle  of  the 
scapula  and  above  the  twelfth  rib.      On  the  right  side,  it  con- 


PHYSICAL    DIAGNOSIS. 


479 


tains  a  portion  of  the  lung,  liver,  and  kidney;  on  the  left  side, 
a  portion  of  the  lung  and  intestine,  spleen,  kidney,  and  descend- 
ing aorta. 


INSPECTION. 

Inspection  signifies  "the  act  of  looking."  Views  of  the  chest 
should  be  taken  from  the  sides  and  behind  as  well  as  from  the 
front,  for  which  purpose  a  good  light  should  be  obtained,  and  the 
patient  be  placed  in  as  easy  and  comfortable  a  position  as  is 
possible. 

Inspection  reveals  the  form,  size,  color,  and  movements  of  the 
chest,  as  well  as  the  condition  of  the  superficial  parts. 

Variations  in  Form. — The  phthisi- 
cal chest  is  characterized  by  a  short 
anteroposterior  diameter  and  a  long 
vertical  diameter.  The  chest  is  flat, 
and  the  ribs  are  oblique.  The  supra- 
and  infra-clavicular  spaces  are  much 
depressed  and  an  acute  angle  is 
formed  at  the  lower  portion  by  the 
divergence  of  the  costal  margins 
from  the  sternum.  Posteriorly  the 
scapulae  are  very  prominent. 

The  rachitic  chest  is  marked  by 
flattening  of  the  sides,  with  promi- 
nence of  the  sternum  (pigeon- 
breast).  Beading  of  the  sternal  ends 
of  the  ribs  (rachitic  rosary)  and  cir- 
cular constriction  of  the  chest  at  the  level  of  the  xiphoid  cartilage 
(Harrison  s  groove)  are  often  present  in  addition. 

The  emphysematous  chest  is  distinguished  by  being  abnormally 
round  and  short.  The  transverse  and  anteroposterior  diameters 
may  be  equal  in  some  cases.  It  is  also  known  as  the  "keg  or 
barrel-shaped  chest."  The  ribs  are  horizontal  and  the  costal 
angle  is  obtuse  or  obliterated. 

Sternal  depressions  are  usually  congenital,  but  may  be  ac- 
quired as  the  result  of  occupation,  as  in  the  case  of  shoemakers. 


Fig.    55-— 3 


Normal    chest ;    2 , 
3,   rickets;   4,   em- 
physema.      (Gee;      modifi  e  d.) 
(Greene's    Medical    Diagnosis.) 


pigeon  breast; 


480  PHYSICAL    DIAGNOSIS. 

Sternal  enlargements  are  generally  congenital. 

Localized  depressions  of  the  chest  may  result  from  pulmonary 
tuberculosis,  fibroid  lung,  or  adhesions  following  pleurisy  or 
other  pulmonic  conditions. 

Localized  or  one-sided  enlargements  may  be  caused  by  pleural 
effusion,  compensatory  emphysema,  tumors  of  the  abdomen  or 
chest,  pneumothorax,  hydro  thorax,  hemothorax,  and  enlarge- 
ment of  the  heart  (left  side).  ^ 

Expansion. — In  health  the  sides  of  the  chest  are  for  the  most 
part  symmetrical  in  form,  size,  color,  and  movements,  both 
sides  rising  equally  during  the  act  of  inspiration,  and  falling 
equally  during  the  act  of  expiration.  During  the  act  of  inspira- 
tion the  intercostal  spaces  in  the  lower  two-thirds  of  the  chest 
become/ more  hollow,  as  do  also  the  supra-clavicular  fossae. 
-  Inspiration  is  almost  entirely  the  result  of  muscular  action ; 
expiration,  on  the  other  hand,  is  .chiefly  due  to  the  elasticity 
of, the  lungs  and  chest-walls,  aided  somewhat  in  forced  respira- 
tion by  muscular  action.  The  movement  of  inspiration  by 
inspection  is  of  longer  duration  than  that  of  expiration,  and  the 
pause  between  the.  acts  but  momentary. 

The  respiratory  movement  is  visible  over  the  whole  thorax, 
although  in  males  and  in  children  it  is  most  distinct  at  the  lower 
^portion  {inferior  costal  breathing) ,  while  in  the  female  it  is  most  dis- 
tinct: at  the  upper  portion  of  the  chest  {superior  costal  breathing) . 

The  abnormal 'varidtions  in  expansion  of  the  chest  are  usually 
unilateral.  Diminished  unilateral  expansion  is  common  to 
acute  pleurisy,  pulmonic  consolidation  from  any  cause,  collapse 
of  the  lung  from  bronchial  obstruction,  tumors,  and  abdominal 
enlargements.  Increased  unilateral  expansion  occurs  in  com- 
pensatory emphysema. 

PALPATION. 

By  palpation  is  meant  the  application  of  the  palmar  surfaces 
of  the  hands  and  fingers  to  the  chest,  by  means  of  which  are 
appreciated  impressions,  that  are  capable  of  being  conveyed 
by  the  sense  of  touch. 


PHYSICAL   DIAGNOSIS.  4^1 

The  objects  of  palpation  are: 

1.  To  give  more  accurate  information  of  what  is  revealed 
by  inspection. 

2.  To  locate  areas  of  tenderness,  the  density  and  condition 
of  tumors,  if  any  be  present;  the  state  of  the  chest  walls,  the 
frequency  of  the  breathing,  and  the  action  of  the  heart.  Tender- 
ness of  the  chest  wall  may  be  produced  by  traumatism,  caries 
and  fracture  of  the  ribs,  intercostal  neuralgia,  pleurodynia,  and 
pleurisy  (alone  or  combined  with  other  lung  conditions  as 
phthisis  and  pneumonia).  Edema  of  the  chest  may  be  due  to 
anasarca,  empyema,  or  ptilmonary  abscess. 

3.  To  determine  the  existence  and  character  of  the  various 
kinds  of  fremitus  (vibrations).  By  fremitus  is  understood 
certain  tactile  impressions  or  vibrations  conveyed  to  the 
surface  of  the  chest,  which  are  classed  and  produced  as 
follows : 

1.  Vocal  fremitus,  produced  by  the  act  of  speaking  or  crying. 

2.  Tussive  fremitus,  produced  by  the  act  of  coughing;  of  value 
especially  when  the  voice  is  very  weak. 

3.  Bronchial  fremitus ,  produced  by  the  passage  of  air  through 
mucus,  blood,  or  pus,  in  the  bronchial  tubes,  during  the  act 
of  respiration. 

4.  Friction  fremitus,  produced  by  the  rubbing  together  of 
the  roughened  surfaces  of  the  pleura. 

When  the  normal  chest  vibrates  lightly,  it  is  termed  the 
normal  vocal  fremitus. 

The  vocal  frentitus  is  more  distinct  upon  the  right  side  toward 
the  apex. 

If  the  lung  be  consolidated  (denser),  the  vibration  is  greater 
and  more  easily  distinguished,  the  vocal  fremitus  is  increased. 
As  examples  of  conditions  with  increased  vocal  fremitus  may 
be  mentioned  croupous  pneumonia,  phthisis,  and  broncho- 
pneumonia. 

In  feeble  persons,  or  when  any  cause  interferes  with  the  trans- 
mission of  the  vibrations,   the  vocal  fremitus  is  diminished  or 
absent.     This    is    observed    in    pleural    effusions,    emphysema, 
collapse  of  the  lung,  tumors,  and  pulmonary  edema. 
31 


482  PHYSICAL    DIAGNOSIS. 

MENSURATION. 

Mensuration,  or  measurement  of  the  chest,  is  of  less  practical 
importance  than  the  other  methods  named,  and  hence  is  seldom 
performed.  The  only  measurement  likely  to  be  required  is  the 
circular  or  circumferential,  in  different  parts  of  the  chest;  this 
is  taken  with  either  an  ordinary  graduated  tape-measure  or  a 
double  tape-measure,  made  by  uniting  two  tapes  in  such  a 
manner  that  they  start  in  opposite  directions  from  the  same 
point  at  the  mid-spinal  line.  The  tapes  drawn  around  each 
side  until  they  meet  at  the  mid-sternal  line,  on  a  line  immediately 
above  the  nipple,  or  on  the  level  of  the  sixth  rib  near  its  attach- 
ment to  the  cartilage — the  sixth  costo-sternal  joint — the 
patient  first  being  directed  to  effect  a  complete  expiration,  the 
number  of  inches  noted,  and  then  to  take  a  deep  inspiration,  the 
increase  in  inches  noted,  the  difference  between  the  two  giving  a 
rough  estimate  of  the  capacity  of  the  lungs. 

In  right-handed  persons  the  right  side  is  usually  1/2  to  3/4 
inch  larger  than"  the  left;  if  larger  than  this,  it  is  usually  the 
result  of  some  abnormal  condition. 

In  well-developed  men,  the  chest  measures  at  the  upper  part 
about  T,^  to  36  inches  during  expiration,  and  is  increased  fully 
3  inches  upon  inspiration. 

PERCUSSION. 

Percussion,  or  "  the  act  of  striking,"  to  ascertain  the  composi- 
tion of  structures,  affords  signs  and  information  of  great  value  in 
diagnosis. 

There  are  two  methods  employed,  immediate  and  mediate. 

Immediate,  or  direct  percussion,  is  performed  by  striking  the 
thorax  directly  with  the  points  of  the  fingers  or  the  palmar  sur- 
face of  the  hand.  This  method  of  percussion  has  been  generally 
abandoned,  as  it  does  not  enable  the  physician  to  distinguish 
with  sufficient  accuracy  between  the  various  shades  of  differ- 
ence in  the  pitch  or  quality  of  percussion  sounds. 

Mediate,  or  indirect  percussion,  may  be  practised  in  three 
different  ways: 


PHYSICAL   DIAGNOSIS.  483 

1.  With  the  finger  of  one  hand  interposed  between  the  body 

percussed  and  the  percussing  finger. 

2.  With  the  finger  acting  as  a  pleximeter  and  the  percussion 
hammer. 

3.  With  the  percussion  hammer  and  the  pleximeter. 

The  first  of  these  modes  affords  the  most  correct  and  ready 
information  regarding  the  resistance  of  the  parts  percussed; 
further,  the  physician  has  his  fingers  with  him.  But  the  skilful 
use  of  the  fingers  is  more  difficult  to  acquire  than  that  of  the 
pleximeter  and  hammer;  and  if  the  examiner  has  acquired 
sufficient  skill  in  its  performance,  an  absolutely  accurate  result 
may  be  obtained.  "  He  who  is  skilled  in  digital  percussion  will 
be  able  to  percuss  equally  well  with  the  hammer,  the  inverse  of 
which  does  not  always  hold  good."  In  addition  to  being  pro- 
ficient in  technic,  it  is  necessary  to  possess  a  sensitive  ear, 
educated  to  distinguish  between  the  various  shades  of  the  sounds. 

When  the  fingers  are  employed,  it  is  a  matter  of  choice 
whether  one  or  more  fingers  are  used  as  the  pleximeter.  Usually 
the  last  phalanx  of  the  first  or  second  fingers  of  the  left  hand  are 
used,  the  other  fingers  being  raised  front  the  chest,  so  as  not  to 
interfere  with  the  sound  vibrations ;  they  should  be  applied  firmly 
and  evenly  to  the  surface,  thus  preventing  the  slipping  of  the 
soft  parts,  and  also  to  determine  the  resistance  of  the  chest 
walls  when  the  blow  is  given.  The  rounded  ends  of  the  first 
and  second  fingers  of  the  right  hand  are  used  as  a  hammer, 
striking  the  pleximeter  fingers  in  such  a  manner  that  the  nails 
shall  not  touch  the  skin  of  the  underlying  fingers.  The  force 
emiployed  varies  in  different  regions,  but  usually,  for  the  chest, 
should  be  only  of  moderate  degree.  Forcible  percussion  is  of 
use  only  when  the  sound  of  deep-seated  organs  is  desired. 

The  stroke  should  be  made  perpendicularly  to  the  surface,  and 
not  slanting,  as  is  too  often  done.  The  whole  movement  should 
proceed  only  from  the  wrist-joint,  and  ought  not  to  be  too  rapid 
or  unequal,  or  of  great  force,  the  fingers  being  rapidly  with- 
drawn, so  as  not  to  interfere  with  the  vibrations. 

The  objects  of  percussion  are  to  elicit  certain  sounds,  and  the 
amount  of  resistance  or  elasticity  of  the  organs  percussed. 


484  PHYSICAL   DIAGNOSIS. 

The  main  sounds  elicited  by  percussion  are  the  dull,  clear,  and 
tympanitic.  Familiarity  with  the  intensity,  character,  and 
pitch  of  each  of  these  sounds  is  essential. 

When  percussing  the  healthy  chest,  the  sound  obtained  is 
termed  the  normal  pulmonary  resonance.  It  is  of  variable 
intensity,  depending  upon  the  force  of  the  stroke  employed  and 
the  amount  of  adipose  and  muscular  tissues  covering  the  thorax, 
and  the  tension  of  the  chest  walls. 

There  is  no  exact  standard  of  the  normal  pulmonary  or  vesic- 
ular resonance,  but  if  the  two  sides  of  the  chest  are  compared, 
the  normal  standard  of  each  person  is  obtained. 

The  character  is  termed  pulmonary  or  clear,  as  characteristic 
of  the  healthy  chest  wall.     The  pitch  is  always  relatively  low. 

The  sounds  elicited  by  percussing  a  healthy  chest  are  not, 
however,  alike  over  all  its  parts. 

Anteriorly,  the  portion  of  lung  above  the  clavicle  yields  a 
sound  which  becomes  somewhat  tympanitic  as  the  trachea  is 
approached. 

Over  the  clavicle  the  sound  is  clear  and  pulmonary  at  the 
center  of  the  bone,  but  at  the  scapular  extremity  it  is  duller,  and 
toward  the  sternum  it  becomes  somewhat  tympanitic. 

At  the  infra-clavicular  region  the  resonance  is  clear  and 
distinct,  but  little  resistance  being  offered  to  the  percussing 
finger,  and  the  sound  elicited  may  be  taken  as  the  type  of  the 
pulmonary  resonance.  In  this  region,  however,  a  slight  dis- 
parity exists  between  the  two  sides;  on  the  right  side  the 
sound  is  less  clear,  shorter,  and  of  a  higher  pitch  than  on  the 
left  side. 

In  the  mammary  region  of  the  right  side  the  resonance  of  the 
lung  is  not  so  clear,  the  sound  being  modified  by  the  size  of  the 
mamma  and  the  upper  border  of  the  liver.  On  the  left  side  the 
heart  deadens  the  sotind  from  the  fourth  to  the  sixth  rib,  and,  in 
a  transverse  direction,  from  the  sternum  to  the  left  nipple.  This 
dull  sound  in  the  left  mammary  region  is  lessened  in  extent  dur- 
ing full  inspiration,  and  in  emphysema,  when  the  lung  more 
completely  covers  the  heart. 

In  the  infra-mammary  region  on  the  right  side  the  percussion- 


PHYSICAL    DIAGNOSIS.  485 

note  is  dull,  except  during  the  act  of  complete  inspiration,  when 
the  liver  is  displaced  downward  by  the  inflated  lung.  In  the 
left  infra-mammary  region  the  sound  consists  of  a  mixture  of  the 
dull  sound  of  the  heart  and  spleen  and  of  the  clear  sound  of  the 
lung,  together  with  the  tympanitic  sound  of  the  stomach.  In 
the  lower  part  of  this  region  is  an  area  known  as  Traube's  semi- 
lunar space,  over  which  the  note  is  tympanitic.  It  is  bounded 
above  by  the  sixth  rib  (corresponding  approximately  to  the 
lower  border  of  the  left  lung),  on  the  left  by  the  spleen,  and  on 
the  right  by  the  liver. 

Over  the  upper  part  of  the  sternum — above  the  third  rib — the 
sound  is  slightly  tympanitic.  Below  the  third  rib,  over  the 
sternum,  the  sound  is  dull,  due  to  the  presence  of  the  heart  and 
liver. 

The  position  exercises  some  influence  on  the  results  of  percus- 
sion. More  accurate  results  are  obtained  when  the  patient  is 
standing  or  sitting  than  when  recumbent.  While  the  front  of  the 
chest  is  percussed,  the  arms  should  hang  loosely  by  the  sides;  the 
hands  may  be  clasped  across  the  top  of  the  head  during  the  per- 
cussion of  the  axillary  region;  during  the  examination  of  the 
back  the  head  must  be  bent  forward  and  the  arms  tightly 
crossed  in  front. 

On  the  posterior  surface  of  the  chest  the  sound  also  varies  ac- 
cording to  the  part  percussed. 

Over  the  scapulce  the  sound  is  duller  than  between  these  bones 
or  below  their  inferior  angles. 

Over  the  infra-scapular  region  a  clear  sound  is  obtained  as 
far  as  the  lower  border  of  the  tenth  rib  on  the  right  side,  where 
the  dullness  of  the  liver  begins.  On  the  left  side,  below  the 
angle  of  the  scapula,  the  percussion-sound  is  tympanitic  if  the 
intestines  are  distended,  or  it  may  be  slightly  dull  if  the  spleen 
is  enlarged. 

In  the  axillary  region  the  sound  is  clear  and  distinct  on  each 
side. 

In  the  infra- axillary  region  of  the  right  side  the  sound  is  duller, 
owing  to  the  presence  of  the  liver ;  at  the  corresponding  situation 
on  the  left  side  the  sound  is  clear  or  tympanitic,  from  the  disten- 


486  PHYSICAL   DIAGNOSIS. 

tion  of  the  stomach,  and  at  the  ninth  or  tenth  rib  of  the  left 
axillary  region,  dullness  and  the  sense  of  resistance  mark  the 
location  of  the  spleen. 

The   sounds   obtained   by   percussion   of   the   unhealthy   or 
abnormal  chest  are  as  follows: 

1.  Hyper-resonance ,  or  an  increase  of  the  normal  pulmonary 
resonance,  is  due  to  the  relative  increase  in  the  proportion  of  air 
to  the  solid  tissues  of  the  lung,  provided  the  tension  of  the  chest 
walls  be  not  altered.  It  occurs  in  emphysema  of  the  lungs, 
atrophy  of  the  lungs,  or  consolidation   of  the   opposing  lung. 

2.  Dullness  or  an  absence  of  resonance,  due  to  the  relative 
increase  of  solid  tissues  in  proportion  to  the  amount  of  air, 
as  seen  in  the  different  stages  of  phthisis,  in  pneumonia,  pleural 
effusion,  and  hydro  thorax. 

The  pitch  is  increased  or  heightened  in  proportion  to  the 
diminution  of  the  amount  of  the  air  and  the  increase  of  the  solids. 

If  there  be  entire  want  of  resonance,  the  percussion-note  is  said 
to  be  flat ;  if  there  is  a  slight  decrease  in  the  resonance  of  the  part, 
the  note  is  said  to  be  impaired. 

The  sense  of  resistance  is  greater  the  more  marked  the  consol- 
idation of  the  lungs  and  the  greater  the  tension  of  the  chest 
walls. 

3.  Tympanitic,  or  the  drum-like  percussion-note,  is  a  non- 
vesicular sound  having  the  character  elicited  by  percussing 
over  the  normal  intestines ;  wherever  heard  it  indicates  the  pres- 
ence of  air  in  conditions  similar  to  that  of  the  intestines,  namely, 
inclosed  in  walls  which  are  yielding,  but  neither  tense  nor  very 
thick. 

When  elicited  over  the  chest  it  may  be  due  to  the  transmitted 
sound  of  the  distended  stomach  or  colon.  It  is  obtained  over 
the  chest  in  pneumothorax,  in  moderate  pleural  effusions  above 
the  level  of  the  liquid,  over  the  seat  of  cavities  in  the  pulmonary 
tissue,  and  in  edema  of  the  lungs. 

The  tympanitic  percussion-note  differs  from  the  normal  pul- 
monary resonance  in  being  more  ringing  in  character  and  of 
a  higher  pitch.  " 

The  amphoric  or  metallic  sound  is  in  reality  a  concentrated 


PHYSICAL    DIAGNOSIS.  487 

tympanitic  sound  of  high  pitch,  and  denotes  a  large  cavity  with 
firm,  but  yet  elastic,  walls. 

The  cracked-pot  or  cracked-metal  sound  is  another  variety  of 
the  tympanitic  soimd.  The  condition  most  frequently  pro- 
ducing this  sound  is  a  cavity  in  the  lung  tissue,  communicating 
with  a  bronchial  tube.  It  requires  for  its  development  a  strong, 
quick  blow  of  the  percussing  finger,  with  the  patient's  mouth 
open. 

Respiratory  Percussion. — The  percussion-sound  will  vary 
greatly  with  the  respiratory  movements.  If  a  full  inspiration, 
be  taken  and  percussion  performed,  then  a  full  expiration 
taken  and  percussion  performed,  and  then  the  chest  percussed 
during  the  normal  respiration,  slight  changes  in  the  character 
and  pitch  of  the  note  are  obtained,  which  otherwise  would 
escape  detection.  Da  Costa  has  designated  this  method, 
respiratory  percussion . 

Auscultatory  Percussion. — This  method  consists  in  listening, 
with  a  stethoscope  applied  to  the  thorax,  to  the  sounds  elicited 
by  percussion.  "  It  is  a  serviceable  means  of  determining  with 
accuracy  the  boundaries  of  various  organs,  as  those  of  the  lungs' 
or  heart,  or  of  the  liver  or  spleen,  and  yields  particularly  exact 
results  when  carried  out  wath  the  double  stethoscope." 

AUSCULTATION. 

Auscultation,  or  listening  to  the  sounds  produced  within  the 
chest  during  the  act  of  respiration,  coughing,  or  speaking, 
furnishes  the  most  reliable  means  of  studying  the  condition  of 
the  lungs  and  heart,  and  is,  therefore,  the  most  valuable  method 
of  discriminating  between  the  various  conditions  w^hich  may 
affect  the  lungs  and  heart. 

Auscultation  is  either  immediate  or  mediate. 

It  is  immediate  when  the  ear  is  applied  directly  to  the  chest, 
which  may  be  either  denuded  or  thinly  covered. 

It  is  mediate  when  the  sounds  are  conducted  to  the  ear  by 
means  of  a  tubular  instrument,  termed  a  stethoscope. 

For  ordinary   purposes,   im,m,ediate   or   direct   auscultation   is 


488  PHYSICAL    DIAGNOSIS. 

sufficient,  but  when  it  is  desirable  to  analyze  circumscribed 
sounds,  as  in  diseases  of  the  heart,  or  where  the  patient  objects  to 
this  method,  on  the  score  of  delicacy,  or  the  auscultator  objects, 
oh  account  of  the  uncleanliness  of  the  person  examined,  the 
stethoscope  is  to  be  preferred.  Moreover,  there  are  certain 
parts  of  the  chest  which  can  only  be  explored  satisfactorily  by 
the  aid  of  a  stethoscope,  which  instrument  has  the  additional 
cidvantage  of  intensifying  the  sound. 

In  auscultation,  the  following  rules,  formulated  by  Da  Costa, 
,  should  be  observed : 

"  I.  Place  yourself  and  your  patient  in  a  position  which  is 
the  least  constrained  and  permits  of  the  most  accurate  applica- 
tion of  the  ear  or  stethoscope  to  the  surface.  Above  all,  avoid 
stooping,  or  having  the  head  too  low. 

"2.  Let  the  chest  be  bare,  or  what  is  better,  covered  only 
with  a  towel  or  thin  shirt. 

"3.  If  a  stethoscope  be  employed,  apply  closely  to  the  surface, 
but  abstain  from  pressing  with  it.  This  may  be  obviated  by 
steadying  the  instrument,  immediately  above  its  expanded  ex- 
tremity, between  the  thumb  and  the  index  finger. 

"4.  Examine  repeatedly  the  different  portions  of  the  chest, 
and  compare  them  with  one  another  while  the  patient  is  breath- 
ing quietly.  Making  him  cough  or  draw  a  full  breath  is  at 
times  of  service;  especially  the  former,  when  he  does  not  know 
how  to  breathe." 

SOUNDS    IN    HEALTH. 

If  the  ear  be  applied  over  the  larynx  or  trachea  of  a  healthy 
person,  a  sound  is  heard  with  both  the  act  of  inspiration  and  ex- 
piration. Its  intensity  is  variable,  its  pitch  high,  and  its  quality 
tubular  (that  is,  like  a  current  of  air  passing  through  a  tube — 
the  larynx  or  trachea).  The  duration  of  the  sound  during  in- 
spiration is  somewhat  longer  than  during  expiration.  A  short 
pause  follows  the  act  of  expiration. 

This  sound  is  termed  the  normal  laryngeal  respiration,  and  is 
identical  in  character,  duration,  and  pitch  with  an  important 
morbid  sound,  termed  bronchial  respiration. 


PHYSICAL   DIAGNOSIS.  489 

The  sound  heard  by  placing  the  ear  over  the  lung-tissue  is 
different;  it  is  produced  in  the  very  finest  bronchial  tubes  and 
air-cells  by  their  expansion  and  contraction,  and  is  termed  the 
normal  vesicular  murmur. 

The  inspiratory  portion  of  the  sound  is  of  variable  intensity, 
its  pitch  is  low,  its  quality  soft  and  breezy,  designated  vesic- 
ular; its  duration  corresponds  to  that  of  the  entire  act  of  in- 
spiration. 

The  expiratory  portion  of  the  sound  is  not  always  perceptible ; 
it  is  of  feeble  intensity,  very  low  pitch,  its  character  soft  and 
blowing,  and  its  duration  much  less  than  the  act  of  inspiration. 

It  is  to  be  remembered,  however,  that  the  vesicular  murmur 
will  be  found  to  vary  in  the  different  regions  on  the  same  side, 
and  in  corresponding  regions  on  the  two  sides  of  the  chest. 
These  variations  within  the  range  of  health  are  especially  im- 
portant, and  should  be  memorized. 

Infra-clavicular  Regions. — The  vesicular  murmur  in  this 
region  on  either  side  is  much  more  distinct  than  over  any  other 
part  of  the  chest. 

On  the  left  side  the  inspiratory  sound  is  of  greater  intensity, 
of  lower  pitch,  and  more  distinctly  vesicular  in  quality  than  that 
heard  upon  the  right  side.  On  the  right  side  the  expiratory 
sound  is  nearly  or  quite  the  same  in  length  as  the  inspiratory 
sound,  and  is  higher  in  pitch  and  more  tubular  in  quality  than 
the  expiratory  sound  upon  the  left  side. 

Supra-scapular  Region. — Owing  to  the  small  number  of  air- 
vesicles  and  the  large  number  of  bronchial  tubes,  and  their 
close  proximity  to  the  surface,  the  respiratory  murmur  has  an 
intense,  high-pitched,  tubular,  and  expiratory  quality. 

Scapular  Region. — Compared  with  the  infra-clavicular  region, 
the  respiratory  murmur  heard  over  the  scapula  on  either  side  is 
more  feeble,  and  the  vesicular  quality  less  marked. 

Inter -scapular  Region. — The  murmur  in  this  region  differs 
from  the  normal  laryngeal  breathing  only  in  intensity  and 
duration. 

Infra-scapular  Region. — The  murmur  in  this  region  very 
closely  resembles  that  heard  in  the  left  infra-clavicular  region. 


490  PHYSICAL    DIAGNOSIS. 

Mammary  and  Infra-mammary  Regions. — The  murmur  in 
these  regions  differs  from  that  heard  in  the  infra-clavicular 
region,   in  being  of  less  intensity. 

Axillary  and  Infra-axillary  Regions  .—The  respiratory  sound 
in  the  axillary  regions  is  as  intense  as  in  any  portion  of  the 
chest.  In  the  infra-axillary  regions  the  intensity  is  less  and  the 
pitch  lower. 

VOICE    IN    HEALTH. 

If  the  ear  b'^  applied  over  the  larynx  or  trachea  of  a  healthy 
person  and  he  be  directed  to  count  "twenty-one,  twenty-two, 
twenty-three,"  in  a  uniform  tone  and  with  moderate  force, 
there  is  perceived  a  strong  resonance,  with  a  sensation  of  con- 
cussion or  shock,  and  a  sense  of  vibration,  thrill,  or  fremitus, 
the  voice  seeming  to  be  concentrated  and  near  the  ear.  Often 
the  articulated  words,  are  distinctly  transmitted  {laryngo phony) . 

The  sounds  heard  are  termed  the  normal  laryngeal 
resonance. 

If  the  ear  or  stethoscope  be  applied  over  the  third  rib  ante- 
riorly, on  either  side  of  the  chest  of  a  healthy  person,  and  he  be 
directed  to  count  "twenty-one,  twenty-two,  twenty-three," 
in  a  uniform  tone,  with  moderate  force,  a  confused  distant  hum 
is  perceived  of  variable  intensity,  accompanied  with  more  or 
less  vibration,  thrill,  or  fremitus,  most  distinct  in  adults,  but 
notably   weaker  in  women  than  in  men. 

This   sound  is  termed  the  normal  vocal  resonance. 

If  the  ear  or  stethoscope  be  applied  over  the  third  rib  ante- 
riorly, of  a  healthy  person,  and  he  be  directed  to  whisper,  in  a 
uniform  manner,  the  words  "  twenty-one,  twenty-two,  twenty- 
three,"  there  is  heard  a  sound  corresponding  closely  in.  character 
to  the  sound  of  expiration  over  the  same  region  during  the  act 
of  forced  respiration;  or,  in  other  words,  a  feeble,  low-pitched, 
blowing  sound. 

This  sound  is  termed  the  normal  bronchial  whisper,  and  is  pro- 
duced by  the  movement  of  the  air  in  the  bronchial  tubes  during 
the  act  of  respiration. 


PHYSICAL    DIAGNOSIS.  49 1 

SOUNDS    IN    DISEASE. 

The  vesicular  murmur  may  undergo,  in  disease,  changes  in 
its  intensity,  its  rhythm,  and  in  its  character. 

The  intensity  of  the  respiratory  murmur  may  be: 

1.  Exaggerated  or  increased. 

2.  Diminished  or  feeble. 

3.  Absent  or  suppressed. 

Exaggerated  respiration  differs  from  the  normal  vesicular 
respiration  only  in  an  increase  in  the  intensity  of  the  respiratory 
sounds.  When  general  over  one  lung,  it  will  usually  indicate 
deficient  action  of  other  parts.  In  this  manner  an  effusion 
compressing  the  lung,  one-sided  deposits,  obstruction  of  the 
bronchial  tubes  by  secretion,  or  inflammation  of  the  lung-struc- 
ture, necessitate  a  supplementary  respiration  in  a  healthy  portion 
of  the  same  lung  or  the  lung  upon  the  opposite  side.  From  its 
resemblance  to  the  loud,  strong,  quick  respiration  of  young 
children,  it  has  been  termed  puerile  respiration.  Exaggerated 
respiration  is,  therefore,  to  be  regarded  as  indirect  evidence  of 
disease  in  some  portion  of  the  pulmonary  tissue. 

Diminished  respiration,  called  also  senile  respiration,  as  being 
characteristic  of  old  age,  is  characterized  by  diminished  intensity 
and  duration  of  the  sound.  In  the  large  majority  of  instances 
the  inspiration  suffers  the  greatest,  the  expiratory  sound  not 
diminishing  in  the  same  proportion.  In  asthma,  emphysema, 
diseases  of  the  larynx  and  bronchial  tubes,  pleuritic  pain, 
rheumatism  or  paralysis  of  the  chest  walls,  or  in  thickening  of 
the  pleural  membrane,  we  observe  superficial  or  diminished 
respiration.  When  one  side  of  the  chest  is  partially  filled 
with  fluid,  v/e  may  hear  a  deep-seated  but  feeble  breath 
sound. 

Absent  or  suppressed  respiration  occurs  whenever  the  action 
of  the  lung  is  suspended;  this  may  be  from  external  pressure,  as 
when  the  lung  is  compressed  by  the  presence  of  fluid  or  air  in  the 
pleural  cavity,  or  when  complete  obstruction  of  the  bronchial 
tubes  prevents  the  air  from  either  entering  or  escaping  from 
the  lungs. 


492  PHYSICAL    DIAGNOSIS.  ~ 

The  rhythm  of  the  respiratory  murm-ur  may  be: 

1.  Interrupted  or  jerky. 

2.  The  interval  between  inspiration   and  expiration  prolonged. 

3.  Expiration  prolonged. 

In  health  the  inspiratory  and  expiratory  sounds  are  even  and 
continuous,  with  a  short  interval  between  each  act;  this  may  be 
altered  in  disease,  and  both  sounds,  especially  the  inspiratory,  have 
an  interrupted  or  jerky  character,  termed  ''cog-wheel  respiration.'' 

This  jerky  breathing  is  noted  in  some  spasmodic  affections  of 
the  air-tubes,  in  hysteria,  the  earliest  stages  of  pleurisy,  pleuro- 
dynia, and  the  early  stages  of  pulmonary  phthisis.  It  is  most 
frequently  associated  with  phthisis,  due  probably  to  the  adher- 
ing to  the  walls  of  the  finer  bronchial  tubes  of  tough  mucus, 
which  obstructs  the  free  entrance  and  exit  of  the  air ;  it  is  usually 
most  notable  under  the  clavicles. 

The  interval  between  inspiration  and  expiration  may  be 
prolonged,  instead  of  these  two  sounds  closely  succeeding  each 
other.  When  this  occurs  the  inspi?atory  sound  may  be  short- 
ened, or  the  expiratory  sound  may  be  delayed  in  its  commence- 
ment. If  the  inspiratory  sound  is  shortened,  it  is  the  result 
of  consolidation  of  the  lungs;  if  the  expiratory  sound  is  delayed, 
it  is  the  result  of  lessened  elasticity  of  the  lung-structure,  and 
is  most  commonly  associated  with  emphysema. 

Prolonged  expiration  denotes  that  the  air  is  obstructed  in  its 
exit  from  the  lungs.  It  may  be  due  to  diminished  elasticity, 
the  result  of  emphysema,  or  from  the  deposit  of  tubercles,  which 
impair  the  contractile  power  of  the  lungs.  If  the  former,  it  is 
associated  with  clearness  on  percussion;  if  the  latter,  with 
impaired  resonance  on  percussion.  When  prolonged^  expira- 
tion is  detected  at  the  apex  of  the  lung,  and  is  associated  with 
impairment  of  the  normal  pulmonary  resonance;  it  is  for  the 
most  part  the  result  of  a  tubercular  deposit. 

The  quality  of  the  respiratory  murmur  may  be: 

1.  Harsh,  termed  broncho -vesicular  respiration. 

2.  Bronchial. 

3.  Cavernous. 

4.  Amphoric. 


PHYSICAL   DIAGNOSIS.  493 

Harsh  respiration,  or,  as  it  is  termed  broncho-vesicular  respira- 
tion is  that  variety  in  which  both  the  inspiratory  and  ex- 
piratory sounds  have  lost  their  natural  -softness.  It  gen- 
erally indicates  more  or  less  consolidation  of  lung-tissue.  In 
normal  vesicular  respiration  the  sounds  produced  by  the  air 
expanding  the  air-cells  and  finer  bronchial  tubes  obscure  the 
sound  produced  by  the  passage  of  air  through  the  larger  bron- 
chial tubes,  the  healthy  lung  being  an  imperfect  conductor  of 
sound,  so  that  as  soon  as  any  portion  of  the  lung  becomes  con- 
solidated the  vesicular  element  of  the  respiratory  sound  is 
diminished,  the  bronchial  element  becoming  prominent.  Harsh 
respiration  is,  then,  a  union  of  the  vesicular  and  bronchial  sounds, 
being  a  vesicular  sound  mixed  with  some  of  the  qualities  of  a 
bronchial  sound,  the  expiration  being  prolonged  and  tubular  in 
character.  It  is  present  when  the  bronchial  mucous  mem- 
brance  is  swollen,  as  in  the  earlier  stages  of  bronchitis,  also  in 
the  earlier  stages  of  phthisis  and  pneumonia. 

Bronchial  respiration  is  characterized  by  an  entire  absence  of 
all  the  vesicular  quality.  Inspiration  is  of  high  pitch  and  tubular 
in  character;  expiration  is  still  higher  in  pitch,  of  greater  inten- 
sity, prolonged  and  tubular  in  quality;  the  two  sounds  being 
separated  by  a  brief  interval.  The  bronchial  respiration  en- 
countered in  disease  closely  resembles  that  heard  in  health  over 
the  larynx  or  trachea.  Whenever  bronchial  respiration  is 
present  where,  in  health,  the  normal  vesicular  murmur  should 
be  heard,  it  indicates  consolidation  of  the  lung-structure. 

Cavernous  respiration  is  a  variety  of  the  bronchial  respira- 
tion, at  least  so  far  as  the  quality  of  the  sound  is  concerned.  It 
is  essentially  a  blowing  sound,  yet  not  always  heard  during 
both  the  acts  of  inspiration  and  expiration,  being  often  only 
perceptible  in  the  one,  and  in  the  other  mixed  with  gurgling 
sounds.  ■  Its  pitch  is  lower  than  that  of  ordinary  bronchial 
respiration,  and  its  character  is  hollow.  For  its  production 
there  must  be  a  cavity  of  considerable  size  in  the  lung-substance, 
not  filled  with  fluid,  near  the  surface  of  the  chest-walls,  com- 
municating with  a  bronchial  tube.  It  is  met  with  most  com- 
monly in  the  last  stages  of  pulmonary  consumption,  although 


494  PHYSICAL   DIAGNOSIS. 

hollow  spaces  of  any  kind,   from  abscess  or  dilatation  of  the 
bronchial  tubes,  occasion  it. 

Amphoric  respiration  is  a  blowing  respiration,  having  a  musi- 
cal or  metallic  quality.  It  is  a  variety  of  bronchial  respiration 
produced  in  a  large  cavity  with  firm  walls,  permitting  the 
reflection  of  the  sound.  An  imitation  of  this  sound,  though 
only  an  imperfect  one,  is  produced  by  blowing  over  the  mouth 
of  an  empty  bottle.  The  amphoric  character  is  present  with 
both  the  acts  of  inspiration  and  expiration.  Amphoric  or 
metallic  respiration  is  indicative  of  a  large  cavity,  not  common 
in  phthisis,  but  more  often  heard  at  the  upper  part  of  a  lung 
compressed  by  fluid  air,  as  in  pneumo-hydrothorax. 

RALES. 

Rales,  or,  as  they  are  termed,  adventitious  sounds,  because 
they  have  no  analogue  in  the  healthy  state,  cannot  be  considered 
as  modifications  of  the  normal  respiration. 

Grouped  according  to  the  anatomic  situation  in  which  they 
are  produced,  we  have: 

1.  Laryngeal  and  tracheal  rales. 

2.  Bronchial  rales. 

3.  Vesicidar  rales. 

4.  Cavernous  rales. 

5.  Pleural  rales. 

Rales  may  be  divided  into  two  groups,  according  to  their  char- 
acter, dry  and  moist;  and  may  be  audible  either  during  the  act 
of  inspiration  or  expiration,  or  during  both. 

Dry  rales,  for  the  most  part,  are  produced  by  the  vibration 
of  thick  fluids  which  the  air  cannot  break  up,  and  which,  there- 
fore, temporarily  lessen  the  caliber  of  the  bronchial  tubes. 
When  this  narrowing  exists  in  the  smaller  bronchial  tubes  the 
resulting  sound  is  high-pitched  or  the  rale  is  said  to  be  sibilant 
or  whistling;  when  the  narrowing  exists  in  the  larger  bronchial 
tubes,  the  rale  is  low-pitched,  more  musical  in  character,  or 
sonorous. 

Dry  rales  are  particularly  prone  to  be  dislodged  by  coughing. 


PHYSICAL    DIAGNOSIS.  495 

^  and  when  they  are  uninfluenced  by  the  acts  of  breathing  and 
coughing,  they  do  not  depend  upon  the  presence  of  secretions, 
but  upon  the  narrowing  of  the  air-tubes  from  the  pressure  of 
tumors,  or  from  a  thickened  fold  of  mucous  membrane,  or  from 
a  spasmodic  contraction  of  the  air-tubes. 

Moist  rales  are  those  produced  by  the  air  passing  through 
thin  fluids,  such  as  mucus,  blood,  serum,  or  pus,  during  the 
respiratory  movements.  When  the  fluid  exists  in  the  smaller 
bronchial  tubes,  the  rales  are  termed  synall  bubbling,  mucous, 
or  subcrepitant.  When  the  fluid  is  in  the  large  bronchial  tubes, 
the  rales  are  said  to  be  large  bubbling  or  mucous. 

Moist  rales  are  not  persistent,  but  vary  in  intensity,  and  shift 
their  position  as  the  air  drives  the  liquid  which  occasions  them 
before  it,  during  violent  attacks  of  coughing,  or  after  copious 
expectoration. 

Laryngeal  and  tracheal  rales  are  those  produced  w^ithin  the 
larynx  or  trachea,  and  may  be  either  moist  or  dry.  The  moist 
or  bubbling  sounds,  produced  when  mucus  or  other  liquids  ac- 
cumulate in  this  part  of  the  air-tubes,  frequently  occur  in  the 
moribund  state,  and  are  then  known  as  the  "death  rattle." 
When  not  due  to  this  condition  they  denote  either  insensibility 
to  the  presence  of  liquid,  as  in  stupor  or  coma,  or  inability  to 
remove  liquid  by  the  act  of  expectoration,  as  in  croup  or  inflam- 
mation of  these  parts  in  the  very  feeble. 

The  dry  rales  produced  within  the  larynx  or  trachea  are  gen- 
erally caused  by  spasm  of  the  glottis  as  in  laryngismus  stridulus, 
whooping  cough,  croup,  or  from  the  presence  of  a  foreign  body 
in  the  part. 

Bronchial  rales,  resulting  from  the  passage  of  air  through 
the  thin  liquid,  occasion  bubbling  sounds.  When  the  liquid 
is  present  in  the  large-sized  bronchial  tubes,  the  rales  are  said 
to  be  large  bubbling,  or  large  mucous  rales,  occurring  in  acute 
or  chronic  bronchitis.  When  the  liquid  is  in  the  smaller  bron- 
chial tubes,  the  resulting  rale  is  called  small  bubbling,  small 
mucous  or  subcrepitant,  also  occurring  in  acute  or  chronic 
bronchitis. 

Bronchial  rales,  due  to  the  narrowing  of  the  tube  by  its  spag- 


496  PHYSICAL    DIAGNOSIS. 

modic  contraction,  or  to  the  presence  of  tough,  tenacious 
mucus,  which  is  put  into  vibration  by  the  passage  of  air  through 
the  bronchial  tubes,  are  termed  dry  bronchial  rales.  Frequently 
they  are  suggestive  of  certain  familiar  sounds,  such  as  snoring, 
cooing,  humming,  or  wheezing,  or  they  are  often  musical  tones. 
When  produced  in  the  smaller  bronchial  tubes,  they  are  termed 
sibilant,  or  high-pitched  rales;  when  produced  in  the  larger 
bronchial  tubes,  they  are  termed  sonorous  or  low-pitched  rales 
They  principally  occur  in  the  dry  stage  of  bronchitis,  or  during 
an  asthmatic  paroxysm. 

The  vesicular  rale,  or,  as  it  is  more  commonly  termed,  the 
crepitant  rale,  is  produced  within  the  air-vesicles  or  at  the  termi- 
nal portion  of  the  smaller  bronchial  tubes.  It  is  to  be  distin- 
guished from  very  fine  bubbling  sounds,  or  the  subcrepitant 
rale.  "  //  is  a  very  fine  sound  or  rather  series  of  very  fine 
uniform  sounds,  occurring  in  puffs  and  lirnited  to  inspiration" 
(Da  Costa).  It  resembles  the  noise  occasioned  by  throwing 
salt  on  fire,  or  alternately  pressing  and  separating  the  thumb 
and  finger,  moistened  with  a  solution  of  gum  arable,  and  held 
near  the  ear,  or  rubbing  together  a  lock  of  dry  hair  near  the  ear. 

The  crepitant  rale  is  produced  by  the  movement  of  fluid  in 
the  air-cells  or  in  the  finest  extremities  of  the  bronchial  tubes, 
or  by  the  forcing  open,  during  the  act  of  inspiration,  of  the  air- 
cells  agglutinated  by  exuded  lymph.  These  sounds  may  be 
defined  as  being  very  fine,  dry,  crackling  sounds,  heard  at  the 
end  of  inspiration  only.  They  are  usually  present  in  the  first 
stages  of  pneumonia,  but  when  limited  to  the  apices  are  signifi- 
cant of  the  incipient  stage  of  phthisis. 

Cavernous  rales,  or,  as  they  are  commonly  termed,  gurgling 
rales,  are  produced  in  a  pulmonary  cavity  of  considerable  size, 
containing  a  large  amount  of  liquid  communicating  freely 
with  a  bronchial  tube.  The  sound  is  occasioned  by  the  agita- 
tion of  the  liquid  within  the  cavity,  and  may  be  compared  to 
the  sound  produced  by  the  boiling  of  liquid  in  a  flask  or  large 
test-tube.  The  sound  is  sometimes  high-pitched  or  musical, 
whence  it  has  been  termed  "  amphoric  gurgling,"  but  it  is  gener- 
ally low  in  pitch.     The  rale  is  heard  almost  exclusively  during 


PHYSICAL   DIAGNOSIS.  497 

the  act  of  inspiration,  and  its  diagnostic  importance  relates  to  the 
advanced  stage  of  phthisis. 

Pleural  rales  may  be  either  dry  or  moist. 

Dry  pleural  rales,  or,  as  they  are  more  commonly  termed, 
friction  sounds,  are  occasioned  when  the  surfaces  of  the  pleura 
are  covered  with  a  glutinous  substance  preventing  the  un- 
obstructed movements  of  the  pleural  surfaces  upon  each  other 
during  the  respiratory  acts,  for  in  health  these  movements 
occasion  no  sound  whatever.  The  sounds  are  generally  inter- 
rupted or  irregular,  occurring  during  the  act  of  inspiration  or 
expiration,  or  during  both  acts.  The  character  of  the  sound  is 
vsTriable,  being  termed  rubbing,  grazing,  rasping,  grating,  or 
creaking,  according  to  the  intensity  of  the  respiratory  acts  and 
the  amount  of  exudation. 

They  are  distinguished  by  the  apparent  nearness  of  the 
sound  to  the  ear,  and  are  usually  intensified  by  firm  pressure 
of  the  stethoscope  upon  the  chest.  When  the  chest  is  fixed, 
especially  at  the  lower  two-thirds,  and  the  ear  applied  over 
the  seat  of  the  sound,  it  will  be  found  to  have  disappeared. 
The  sound  is  diagnostic  of  the  first  stage  of  pleurisy  or  the  pre- 
adhesive  stage  of  tuberculosis  of  the  pleura. 

Moist  friction  sounds  are  produced  in  the  same  manner  as 
those  just  mentioned,  the  exudation  being  softened  in  character. 
This  sound  is  frequently  confounded  with  moist  bronchial  rales, 
and  its  discrimination  is  often  only  positive  by  careful  study  of 
the  symptoms  and  concomitant  signs  present. 

Metallic  tinkling  is  a  sign  of  pneumothorax  with  perforation 
of  the  lung,  and  when  found,  is  usually  diagnostic  of  this  affec- 
tion, although  it  occurs  rarely  in  cases  of  phthisis  with  a  large 
cavity,  the  physical  conditions  for  its  production  being  similar 
to  those  in  pneumothorax,  namely,  a  space  of  considerable  size 
containing  air  and  liquid,  the  space  communicating  with  the 
bronchial  tubes. 

It  consists  of  a  series  of  tinkling  sounds,  of  high  pitch,  silvery  or 

metallic  in  tone,  and  is  very  well  imitated  by  dropping  a  small 

marble  into  a  metallic  vase.     It  occurs  irregularly,  not  being 

present  with  every  act  of  breathing,  and  may  be  produced  by 

32 


498  PHYSICAL    DIAGNOSIS. 

force,  when  not  heard  during  tranquil  breathing.  When  it  is 
low-pitched  it  is  sometimes  called  amphoric  tinkling. 
'  Were  it  not  for  the  location  and  the  absence  of  concomitant 
signs,  it  might  be  confounded  with  tinkling  sounds  sometimes 
produced  within  the  stomach  and  transverse  colon;  these  latter 
sounds  must  be  kept  in  mind  in  auscultating  the  lower 
chest  area. 

THE    VOICE    IN    DISEASE. 

The  normal  vocal  resonance,  as  heard  over  the  third  rib  of 
the  chest  anteriorly  on  each  side,  may  have  its  intensity — 

1.  Diminished  or  absent. 

2 .  Increased  or  exaggerated. 

Or  its  resonance  may  be  of  the  character  of — 

3.  Bronchophony. 

4.  Pectoriloquy. 

5.  Ego  phony. 

6.  Amphoric  voice. 

The  vocal  resonance  may  be  diminished  or  feeble  in  bronchitis 
with  free  secretion,  pleurisy  with  effusion,  or  in  complete  con- 
solidation of  the  lung-structure  and  the  bronchial  tubes. 
.     The  vocal  resonance  is  absent  in  pneumothorax  and  in  pleurisy 
with  effusion. 

Exaggerated  vocal  resonance  differs  from  the  normal  vocal 
resonance  in  a  slight  increase  of  its  density.  It  denotes  a  slight 
degree  of  solidification  of  lung-tissue,  and  is  chiefly  of  value  in 
the  diagnosis  of  tuberculosis. 

Bronchophony,  or  the  voice  concentrated  near  the  ear,  raised 
in  pitch  and  in  intensity,  denotes  complete  consolidation  of  the 
pulmonary  tissue  in  those  parts  in  which  the  sound  is  abnormally 
present. 

Pectoriloquy  is  complete  transmission  of  the  voice  to  the  ear, 
the  articulated  words  being  distinctly  recognized.  It  has  a  close 
resemblance  to  the  resonance  heard  over  the  larynx  in  health. 
Its  presence  indicates  either  a  pulmonary  cavity  or  more  complete 
consolidation — in  other  words,  an  exaggerated  bronchophony. 


ASSOCIATION    or    THE    PHYSICAL    SIGNS.  499 

Egophony  is  a  modification  of  bronchophony,  consisting  in 
tremulousness  of  the  voice,  its  character  nasal  or  bleating,  some- 
what suggestive  of  the  cry  of  a  goat.  When  heard  it  may  be 
considered  a  sign  of  pleurisy  with  slight  effusion,  or  pleuro- 
pneumonia. 

Amphoric  voice,  or  "the  echo,"  as  it  is  sometimes  called,  is  a 
musical  sound,  of  a  somewhat  hollow,  metallic  character,  like 
that  produced  by  blowing  into  an  empty  bottle.  It  is  some- 
times produced  in  large  cavities  within  the  lung,  but  is  especially 
incident  to  pneumothorax. 

Increased  bronchial  whisper  is  a  sound  in  which  the  whispered 
words  are  abnormally  intense,  and  higher  in  pitch  than  the 
normal  bronchial  whisper.  It  has  the  same  significance  as 
exaggerated  vocal  resonance. 


SUCCUSSION. 

The  succussion  or  splashing  sound  is  pathognomonic  of  one 
affection — namely,  pneumohydrothorax. 

It  is  obtained  by  jerking  the  body  of  the  patient  with  a  quick, 
somewhat  forcible  movement,  the  ear  being  very  near  or  in 
contact  with  the  chest. 

The  sound  is  like  that  produced  when  a  small  keg,  partially 
filled  with  liquid  is  shaken.  The  only  liability  to  error  is  in 
confounding  this  splashing  sound  with  that  sometimes  produced 
within  the  stomach;  but  attention  to  concomitant  signs  and 
the  symptomis  will  always  protect  against  this  error. 

ASSOCIATION  OF  THE  PHYSICAL  SIGNS 

(da  costa). 

"  As  many  of  the  signs  elicited  by  the  various  methods  of 
physical  diagnosis  depend  on  the  same  physical  conditions,  they 
may  be  studied  in  groups.  The  following  will  be  usually  found 
to  be  associated. 


500 


GENEEAL    SYMPTOMATOLOGY. 


Percussion. 


Ascultation  of 
respiration. 


Auscultation  of 
voice. 


Vocal 
fremitus. 


Physical  condi- 
tions. 


Clear, 


Dull, 


Tympanitic, 


Vesicular  m  u  r- 
mur  or  its 
modification. 


Bronchial  or 

harsh  respira- 
tion. 


Absent 
tion. 


Normal      vocal 
resonance. 


Bronchophony.       Increased . 


Unimpaired. 


respira- 


Absent  voice. 


Cavernous  or  Uncertain ;  caver- 
feeble,  accord-  nous  or  dimin- 
ing  to  cause.  ished. 


Amphoric  or    Amphoric  or  me-:   Amphoric  or  me- 
metallic tallic.  tallic. 


Cracked -m  e  t  a  1 
sound, 


Cavernous  respi- 
ration. 


Cavernous   respi- 
ration. 


Diminished 
or  absent. 

Uncertain ; 
chiefly     di- 
minished. 


Mostly       di- 
minished. 

Uncertain. 


Lung-tissue 
healthy  or 
nearly  so ;  at 
any  rate,  no 
increased  den- 
sity from  de- 
posits, etc. 

Solidification  of 
pulmonary 
structure. 

Effusion  into 

pleural  sac. 

Increased  quan- 
tity of  air  within 
the  chest,  due 
to  a  cavity  or  to 
o  V  e  r  d  istention 
of  the  air-cells. 

Large  cavity  with 
elastic  walls. 

Generally  a 
cavity  commu- 
nicating with  a 
bronchial  tube. 


GENERAL  SYMPTOMATOLOGY. 


Dyspnea  (or,  as  patients  often  call  it,  "shortness  of  breath'')  is 
the  term  used  to  denote  difficult  or  impaired  breathing.  It  may 
be  inspiratory,  expiratory,  or  both;  and  there  may  be  an  in- 
crease in  frequency,  or  depth,  or  both,  of  the  respirations.  It 
is  attended  by  varying  degrees  of  distress  and  when  its  severity 
requires  the  patient  to  sit  up  constantly  it  is  called  orthopnea. 

Dyspnea  may  be  due  to  obstruction  of  the  air-passages,  pres- 
sure upon  the  respiratory  system  from  without  by  tumors,  and 
distention  of  abdomen,  diseases  of  the  lungs  and  pleura,  heart 
disease,  asthma,  anemia,  or  paralysis  of  muscles  of  respiration 
as  the  result  of  hemorrhage,  tumors,  or  degeneration  of  the 
respiratory  center  in  the  medulla  or  toxic  agents  in  the  blood. 

It  may  be  inspiratory  when  it  results  from  obstruction  as  in 
foreign  bodies  in  the  larynx  or  trachea,  or  it  may  be  expiratory 


GENERAL    SYMPTOMATOLOGY.  5OI 

as  in  emphysema,  or  bronchial  asthma.  A  combination  is  the 
more  frequent  condition. 

In  all  forms  of  dyspnea  it  is  important  to  determine  whether 
the  shortness  of  breath  bears  any  relation  to  exertion.  Dyspnea 
independent  oj  exertion  is  a  serious  condition  and  is  symptomatic 
of  severe  cardiac  and  pulmonary  disease.  Dyspnea  dependent 
upon  exertion  is  less  serious  and  is  observed  in  health,  simple 
debility,  anemia,  obesity  and  somewhat  moderate  cardiac 
debility. 

The  rate  of  respiration  varies  greatly  in  dyspnea.  Normally 
the  respiratory  rate  is  about  18  per  minute  in  adult  males,  being 
somewhat  more  rapid  in  women  and  children.  Dyspnea  with 
slow  or  normal  breathing  is  observed  in  diabetic  coma,  and 
again  the  breathing  may  be  slow  and  stertorous  as  in  coma  of 
central  origin.  Rapid  respiration  occurs  in  inflammatory 
pulmonary  disease,  pleurisy,  painful  affections  of  the  chest 
muscles,  heart  disease,  fever,  hysteria,  toxic  conditions  affecting 
the  respiratory  centers,  anemia,  and  morbid  conditions  at  the 
base  of  the  brain.  Irregularity  in  the  respiratory  rate  in  dysp- 
nea may  also  be  observed.  Cheyne-Stokes  breathing  is  the 
term  applied  to  this  condition  when  the  respirations  gradually 
increase  in  rapidity  and  depth  until  a  climax  is  reached,  after 
which  there  is  a  period  of  apnea  or  absence  of  breathing.  The 
paroxysm  is  then  repeated.  It  is  a  serious  indication  and  may 
be  observed  in  meningitis,  apoplexy,  cerebral  tumor,  fatty 
degeneration    of    the    heart,    uremia,    and    similar    conditions. 

Dyspnea  may  be  constant  or  paroxysmal.  Constant  dyspnea 
is  always  due  to  a  persistence  of  its  cause.  Paroxysmal  dyspnea 
is  seen  in  asthma  and  cardiac  affections.  It  may  follow  exer- 
tion in  various  central  or  reflex  conditions.  It  is  most  marked 
at  night. 

Cough  may  be  brought  about  by  reflex  irritation,  hysteria,  or 
direct  irritation  as  the  result  of  the  inhalation  of  irritant  vapors 
or  dust,  or  the  presence  of  foreign  bodies ;  but  is  usually  due  to 
inflammatory  conditions  of  the  pharynx,  larynx,  trachea, 
bronchi,  or  lungs.  In  the  early  stages  of  inflammation  of  any 
portion  of  the  respiratory  tract,  and  when  excited  reflexly,  it 


502  GENERAL   SYMPTOMATOLOGY. 

occurs  without  expectoration  and  is  termed  dty  cough.  With 
the  occurrence  of  exudation  and  outpouring  of  serum,  blood, 
etc.,  the  cough  is  attended  by  expectoration  and  is  called  moist 
cough.  Laryngeal  conditions,  whooping  cough,  hysteria,  and 
recurrent  laryngeal  nerve  irritation  are  attended  by  a  cough 
having  a  metallic  ringing  intonation.  This  is  laryngeal  or 
croupy  cough. 

Sputum  may  vary  in  its  several  characteristics  according  to 
the  morbid  condition  present.  Mucoid  sputum  is  glairy,  clear, 
and  tough  and  contains  considerable  mucin.  It  may  be  ob- 
served in  health  but  occurs  with  great  frequency  in  the  early 
stages  of  acute  bronchitis,  pneumonia,  and  phthisis,  in  asthma, 
and  in  pulmonary  edema.  Watery  or  serous  sputum  occurs  in 
pulmonary  edema  and  is  frothy  in  character.  Muco-purulent 
sputum  is  made  up  of  varying  proportions  of  mucus  and  pus. 
It  is  encountered  usually  in  subacute  and  chronic  bronchitis, 
pneumonia  in  the  stage  of  resolution,  and  phthisis.  Purulent 
sputum  is  that  which  is  made  up  almost  entirely  of  pus.  This 
is  a  rare  condition  and  occurs  in  abscess  of  the  lung,  or  adjacent 
viscera  discharging  into  a  bronchus,  tubercular  cavities,  bron- 
chiectasis, and  empyema.  Nufnmular  sputum  is  that  variety 
which  occurs  in  round,  fiat  disks  which  sink  when  placed  in 
water;  when  spherical  it  is  termed  globular  sputum.  It  accom- 
panies advanced  tuberculosis  and  bronchiectasis.  Fetid  spu- 
tum, is  that  which  when  allowed  to  rest  undisturbed  separates 
into  three  distinct  layers;  the  upper  layer  being  composed  of 
a  frothy,  watery  material;  the  middle  layer  being  made  up  of 
a  greenish  mucoid  substance;  and  the  bottom  layer  consisting 
of  pus  and  debris.  It  is  a  symptom  of  gangrene  of  the  lung, 
bronchiectasis,  and  advanced  cavity  formation.  Fibrous 
sputum,  contains  many  fibrous  shreds  and  may  be  seen  in  the 
various  inflammations  attended  with  fibrin  formation  as  fibrin- 
ous bronchitis,  diphtheria,  etc.  The  rusty  sputum,  is  a  form 
encountered  in  lobar  pneumonia,  of  which  it  is  characteristic. 
It  is  due  to  the  admixture  of  a  small  quantity  of  bright  fresh 
blood  with  the  thick  tenacious  mucus  present.  When  the 
blood  is  retained  in  the  vesicles  and  bronchioles  it  becomes 


GENERAL   SYMPTOMATOLOGY. 


503 


altered  and  forms  the  prunc-juice  sputum.  In  gangrene,  can- 
cer, and  low  forms  of  croupou-s  pneumonia  it  may  be  observed. 
A  further  degeneration  of  the  blood  in  the  lungs  as  in  malignant 
disease  gives  rise  to  the  production  of  currani-jclly  sputum. 
The  sputum  observed  in  hepatic  abscess  contains  blood,  pus,  bile 
elements,    and    amebse,    and    is    called   reddish-brown   sputum. 

The  Microscopic  Examination  of  the  Sputum. —  Blood  corpus- 
cles and  alveolar  cells  are  present  in  the  sputum  and  may  be 
detected  by  the  aid  of  the  microscope  with  or  without  staining. 

Elastic  fibers  in  the  sputum  are  of  great  importance,  as  their 
presence  signifies  destruction  of  tissue  somewhere  in  the  re- 
spiratory tract.  They  are  found  in  phthisis,  gangrene,  and 
bronchiectasis.  They  are  usually  detected  in  the  sediment 
that  is  formed  after  boiling  equal  parts  of  the  sputum  with  a 
10  per  cent,  solution  of  caustic  potash.  The  elastic  tissue 
remains  intact  in  the  sediment.  Resort  to  the  microscope  will 
enable  the  examiner  to  detect  the  individual  fibers. 

Connective  tissue  and  cartilage  may  in  very  rare  instances  be 
present  in  the  sputum  and  are  of  grave  significance.  The 
former  may  accompany  pulmonary  abscess 
or  gangrene,  while  the  latter  attends  laryn- 
geal ulceration. 

Curschmann  s  spirals  {mucin  spirals)  are 
found  in  the  sputum  in  bronchial  asthma 
and  occasionally  in  pneumonia,  capillary 
bronchitis,  and  chronic  pulmonary  tuber- 
culosis. They  are  made  up  of  spirally 
arranged  mucin,  more  or  less  twisted,  to- 
gether with  epithelium  and  Charcot- 
Leyden  crystals,  and  represent  molds  of 
the  finer  bronchioles.  In  section,  they  stain  blue  with  Weigert's 
fibrin  method. 

Crystals. — Charcot-Leyden  crystals  are  colorless,  octahedral, 
sharply  pointed  crystals  resembling  grains  of  sand.  They  are 
soluble  in  warm  water,  alkalies,  acetic  acid,  and  the  mineral 
acids.  They  are  particularly  abundant  in  bronchial  asthma, 
but   may   at  times  be   detected   in   the   sputum  of  acute   and 


A  B 

Fig.  56. — Curschmann's 
spirals.  A,  unmagnified 
B,  magnified.  {Greene's 
Diagnosis.) 


504  GENERAL    SYMPTOMATOLOGY. 

chronic  bronchitis  and  tuberculosis,  in  leukemic  blood,  in  semen, 
and  in  the  feces.  Cholesterin  crystals  occur  in  the  sputum  in 
tuberculosis,  abscess  of  the  lung,  and  liver  abscess,  discharging 
through  a  bronchus.  They  appear  as  thin,  rhombic  plates, 
with  irregular  comers.  Crystals  of  the  fatty  acids,  particularly  of 
margaric  acid,  are  found  in  purulent  pulmonary  conditions 
such  as  gangrene,  bronchiectasis,  etc.  They  appear  as  long, 
thin  needles,  occurring  singly  or  in  bundles,  and  not  unlike 
elastic  fibers.  Hematoid  crystals  appear 
under  the  microscope  as  small  rhomboid 
prisms  or  needles,  or  as  free  pigment  part- 
icles of  a  brownish  yellow  or  ruby-red  color. 
They  occur  in  the  sputum  in  pulmonary 
hemorrhage,  abscess,  cancer,  gangrene,  and 
tuberculosis. 

Method  for  the  Detection  of  Tubercle  Bacilli. 

Fig       '>^   Tubercle 

bacilli'  in*  sputum.    — The  significance  of  the  presence  of  tubercle 

(From  Greene's  Medical     ,         •n--        .1  ,  •  1       1,-1        ,1 

Diagnosis.)  bacilli    m  the   sputum   is  undoubted — they 

indicate  the  presence  of  tuberculosis;  but 
inability  to  find  them  does  not  necessarily  imply  an  absence  of  the 
disease.  The  bacillus  is  a  straight  or  slightly  curved,  non-motile 
organism,  varying  in  length  from  2  to  5  microns.  Staining  is 
necessary  for  its  detection.  When  stained,  it  often  presents  a 
beaded  appearance,  due  to  the  spores.  To  examine  the  sputum 
for  tubercle  bacilli  a  small  caseous  particle  should  be  selected 
and  spread  out  in  a  very  thin  layer  on  a  cover-glass  or  slide.  It 
is  allowed  to  dry  in  the  air  or  by  passing  it  through  the  flame  of 
a  Bunsen  burner  (smeared  side  up)  three  times.  Ziehl's  carbol- 
fuchsin  stain  (fuchsin  i;  alcohol  10;  5  per  cent,  aqueous 
solution  of  carbolic  acid  90)  is  then  poured  generously  over 
the  entire  specimen ;  which  should  then  be  held  a  short  distance 
above  the  flame  for  a  few  seconds  until  steam  is  formed.  The 
slide  or  cover-glass  should  then  be  thoroughly  washed  in  run- 
ning water  to  remove  the  excess  of  the  stain.  Gabbet's  solution 
(methylene-blue  2;  sulphuric  acid  25;  water  75)  is  then  em- 
ployed to  counterstain  the  preparation,  for  which  a  period  of 
about  thirty  seconds  is  required.     The  excess  of  this  stain  is 


ACUTE  NASAL  CATARRH.  505 

also  removed  by  running  water,  after  which  the  specimen  is 
dried  and  mounted  in  Canada  balsam.  When  viewed  through 
a  1/12  oil  immersion  lens,  the  tubercle  bacilli  appear  as  red 
rods  on  a  blue  background. 


DISEASES  OF  THE  NASAL  PASSAGES. 

ACUTE  NASAL  CATARRH. 

Synonyms. — Acute  rhinitis;  acute  coryza;  "cold  in  the  head." 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  (pituitary  or  Schneiderian  membrane)  lining '  the 
nose  and  the  cavities  communicating  with  it;  characterized 
by  feverishness,  feeling  of  fullness  and  discomfort  in  the  head, 
and  attended  with  discharges  of  fluid,  watery,  mucous,  or 
muco-purulent  in  character. 

Causes. — Atmospheric  changes,  exposure  of  the  neck  to  a 
draught  of  cold  air,  or  of  the  ankles  to  cold  and  dampness, 
changing  from  a  warm  to  a  cold  atmosphere  suddenly,  inhalation 
of  irritant  gases  and  vapors,  dust,  and  powders,  such  as  ipecac 
and  tobacco  are  the  most  common  causes.  The  scrofulous  taint 
and  the  rheumatic  diathesis  seem  to  render  the  mucous  mem- 
brane susceptible  to  frequent  attacks.  Acute  coryza  is  often 
present  in  the  initial  stage  of  the  infectious  fevers,  such  as 
measles,  influenza,  and  erysipelas.  Syphilis,  and  potassium 
iodid  in  large  doses  may  at  times  produce  it.  Occasionally  the 
affection  seems  to  be  contagious  in  character,  and  epidemics 
are  observed. 

Pathology. — In  the  early  stage  there  is  hyperemia  of  the 
mucous  membrane,  attended  with  redness,  "swelling,  and  de- 
ficient secretion.  This  tumefaction  is  partly  increased  by  an 
edematous  infiltration,  causing  a  quantity  of  colorless,  salty, 
and  very  thin  liquid  to  flow  from  the  nose.  The  secretion  soon 
assumes  the  character  of  thick,  tenacious  mucus  or  muco-pus 
due  to  the  desquamation  of  the  epithelium  of  the  nasal  mucous 
membrane,  and  a  copious  generation  of  young  cells,  the  hy- 


5o6  ACUTE    NASAL    CATARRH. 

peremia  and  the  swelling  of  the  membrane  diminishing.  The 
respiratory  portions  of  the  nasal  foss«  are  more  markedly 
affected  than  are  the  olfactory.  Rarely,  and  then  in  new-born 
infants  and  those  affected  with  the  eruptive  fevers,  the  exuda- 
tion in  the  nasal  passages  is  of  a  fibrinous  nature,  somewhat 
similar  to  that  observed  in  diphtheria. 

Symptoms. — "A  cold  in  the  head"  is  usually  preceded  by  a 
feeling  of  lassitude  or  weariness  and  more  or  less  frontal  head- 
ache; then  occur  irregular  chilly  sensations  in  the  back,  followed 
by  more  or  less  feverishness  and  an  uncomfortable  feeling  of 
dryness  in  the  nares,  with  a  strong  inclination  to  sneeze.  This 
is  soon  followed  by  an  abundant  water}^  and  saline  discharge, 
which  is  continually  dripping  from  the  nostrils,  or  occasions  an 
attack  of  sneezing  followed  by  blowing  the  nose,  which  relieves 
the  congested  and  swollen  membrane  for  a  few  moments.  The 
relief  is  only  tempora^ry,  however,  the  fullness  of  the  head  and 
difficult  obstructed  nasal  respiration  rapidly  returning.  The 
anterior  nares  are  red  and  infiamed,  and  the  eyes  red  and 
suffused  with  tears,  through  partial  or  entire  closure  of  the 
tear-ducts.  The  discharge  soon  assumes  a  purulent  character. 
The  voice  has  a  peculiar  tone,  rather  nasal  and  muffied  in 
character.  Within  a  few  days  the  swelling  subsides  and  secre- 
tion lessens,  health  being  restored  in  about  ten  days  from 
the  beginning  of  the  attack.  When  the  attack  has  almost 
terminated,  hard  crusts  may  form  within  the  nostrils,  either  on 
the  septum  or  turbinated  bones,  which  are  with  difficulty  ex- 
pelled by  blowing  the  nose. 

Complications. — Repeated  blowing  of  the  nose  and  constant 
irritation  by  the  discharges  often  causes  swelling  of  the  upper 
lip.  The  catarrhal  infiammation  may  extend  to  the  ethmoid  or 
sphenoid  cavities,  or  the  frontal  sinus,  causing  increased  and 
severe  frontal  headache,  or  to  the  antrum  of  Highmore,  causing 
tenderness  over  one  or  both  cheeks.  Extension  to  the  Etistachian 
tube  and  middle  ear  will  cause  temporary  deafness  and  exten- 
sion to  the  pharynx  or  larynx  will  give  rise  to  cough.  Con- 
junctivitis may  also  occur  as  the  result  of  extension  through 
the  nasal  duct. 


ACUTE    NASAL    CATARRH,  507 

Prognosis. — If  the  appropriate  treatment  is  instituted 
promptly,  mild  cases  will  terminate  favorably  in  aVjout  a  week, 
and  severe  cases  in  two  or  more  weeks.  Neglected  cases  tend  to 
become  chronic.  In  very  young  infants,  if  the  catarrh  is  not 
rapidly  relieved,  loss  of  flesh  and  strength  will  follow  on  account 
of  the  inability  to  nurse. 

Treatment. — When  due  to  atmospheric  causes  the  early 
administration  of  quinin  sulphate,  gr.  x  to  xv  (0.6  to  i  gm.), 
with  morphin  sulphate,  gr.  1/4(0.016  gm.),  or  Dover's  powder, 
gr.  V  (0.3  gm.),  repeated  in  two  hours,  will  often  serve  to  abort 
an  attack.  A  hot  foot-bath  or  full  bath,  together  with  rest  and 
purgation  by  saline  laxatives,  aids  this  abortive  treatment 
materially.  Sodium  bicarbonate,  gr.  xx  (1.3  gm.),  in  two 
fluidounces  (60  c.c.)  of  hot  water  every  half  hour  for  3  doses 
(the  fourth  dose  to  be  given  after  an  hour's  interval)  has  been 
recommended  as  an  efficient  abortive  treatment.  The  follow- 
ing used  at  the  very  onset  has  often  proved  successful: 

J^.      Aluminis 

Bismuth  subcarb. 

Pulv.  camphorae aa  gr.  xx  aa  i .  3     gm. 

Morphinae  hydrochlor  .  .  .    gr.  ij  .  13  gm. 

M.     Ft.  chart.  No.  xx. 

S. — Insufflate  one  powder  in  each  nostril  after  clearing  the 
nose. 

If  the  attack  has  already  developed,  relief  is  soon  afforded 
by  the  use  of  tincture  of  belladonna,  nxii  (0.12  c.c),  every  hour 
until  6  doses  are  taken,  after  which  i  drop  every  two  or  three 
hours  until  the  physiologic  effects  of  the  drug  are  manifest.  If 
much  fever  is  present  tincture  of  aconite,  n^v  (0.3  c.c),  may 
be  added.  Camphor  in  full  doses  at  the  onset  is  also  of  value. 
Sajous  recommends  the  following: 

Ff.     Ammonii  chlor gr-  xl  2.6  gm. 

Tinct.  opii rr^xxx  2  .     c.c. 

Sacch.  alb oj  4.     gm. 

Aq.  camphorae f  §j  30.     c.c. 

M.  S. — One  teaspoonful  in  water  every  hour  or  two. 


5o8  CHRONIC    NASAL   CATARRH. 

Attacks  of  acute  rhinitis,  unattended  by  febrile  reaction,  may 
generally  be  lessened  or  promptly  aborted  by  spraying  the  nares 
with  a  4  per  cent,  solution  of  cocain  hydrochlorid  or  adrenalin 
chlorid  (i  to  5000).  The  danger  of  cocain  habit  should  always 
be  kept  in  mind  when  employing  the  former. 

Acute  coryza  in  nursing  infants  may  be  controlled  by  the  in- 
sufiflatio|i  into  the  nose  of  finely  powdered  white  sugar,  or  equal 
parts  of  powdered  white  sugar  and  powdered  camphor,  or 
powdered  sugar,  5iv  (15  gm.),  powdered  camphor,  oiv  (15  gm.), 
and  tannic  acid,  gr.  xl  (2.6  gm.). 

Most  cases  of  coryza  in  very  young  children  are  usually  of 
syphilitic  origin  and  require  specific  treatment.  Symptomatic 
coryza  necessitates  no  special  treatment.  In  all  cases  cleansing 
of  the  nose  with  alkaline  solutions,  especially  Dobell's  solution, 
will  be  of  value. 

CHRONIC  NASAL  CATARRH. 

Synonyms. — Chronic  rhinitis;  chronic  coryza;  ozena. 

Definition. — A  chronic  inflammation  of  the  mucous  membrane 
lining  the  nasal  passages,  with  more  or  less  alteration  of  struc- 
ture; characterized  by  a  sensation  of  fullness  in  the  nares,  in- 
creased secretion,  and  a  perversion  of  the  senses  of  smell  and 
hearing. 

Causes. — It  may  occur  as  the  result  of  repeated  attacks  of  the 
acute  variety;  inhalation  of  irritating  vapors  and  dust;  syphilis 
and  scrofula. 

Pathologic  Anatomy. — Two  forms  are  recognized:  i.  Hyper- 
trophic rhinitis,  in  which  the  mucous  membrane  of  the  nares 
is  thickened,  of  a  dark  red  sometimes  grayish  color,  the  super- 
ficial veins  are  dilated  and  varicose,  often  forming  polypoid 
enlargements.  2.  Atrophic  rhinitis.  In  many  cases  there  is  ul- 
ceration of  the  structure,  with  more  or  less  loss  of  substance; 
the  secretion  is  thick,  tough,  of  a  greenish  character,  and  often 
very  fetid;  large  collections  of  dried  mucus  are  often  formed 
upon  the  turbinated  bones  and  septum. 

Symptoms. — There  is  a  feeling  of  fullness  in  the  nose,  with 
increased  secretion  of  thick  and  greenish  muco-purulent  material 


CHRONIC    NASAL    CATARRH.  509 

which,  dropping  posteriorly  into  the  pharynx,  causes  paroxysms 
of  "hawking,"  most  marked  in  the  morning  immediately  after 
rising.  The  sense  of  smell  is  more  or  less  impaired  and  in  many 
instances  entirely  abolished;  hearing  is  diminished  in  many  in- 
stances due  to  extension  of  the  inflammation  to  the  Eustachian 
tube.  The  voice  has  a  peculiar  nasal  intonation.  Mouth- 
breathing  is  common  on  account  of  the  nasal  obstruction.  There 
is  an  almost  constant  dull  frontal  headache,  associated  with  a 
feeling  of  weight,  indicating  extension  of  the  disease  to  the 
infundibulum  and  frontal  sinus.  When  the  affection  extends 
to  the  nasal  duct,  lacrimation  and  congestion  of  the  conjunctiva 
result. 

In  the  atrophic  form,  there  is  marked  shrinkage  of  the  mucous 
membrane,  which  is  pale  and  dry.  The  secretion  is  thick  and 
greenish  and  dries  within  the  nasal  chambers,  forming  large, 
offensive  crusts,  the  odor  of  which  is  characteristic.  Ulcera- 
tion is  not  uncommon  and  necrosis  of  the  bones  may  occur. 
This  form  of  the  affection  is  termed  ozena. 

In  all  varieties,  sudden  changes  in  the  atmosphere  are  liable 
to  give  rise  to  acute  exacerbations,  which  invariably  lead  to 
exaggeration  of  all  the  symptoms. 

Diagnosis. — While  the  symptoms  are  suggestive  of  the  varie- 
ties of  this  affection,  the  diagnosis  can  only  be  made  positively 
by  rhinoscopic  examination. 

Prognosis. — Permanent  cure  is  seldom  obtained;  the  disease 
being  so  decidedly  chronic  and  obstinate,  the  treatment  is  of 
necessity  protracted,  and  the  majority  of  patients  tire  of  it 
before  a  complete  cure  is  effected.  In  ozena,  the  prognosis 
as  to  cure  is  unfavorable,  but  much  can  be  done  to  relieve  the 
symptoms  by  appropriate  treatment.  Unfortunately,  by  reason 
of  impairment  of  the  sense  of  smell,  the  patient  is  unable  to  detect 
the  offensive  odor  the  crusts  produce,  and  neglects  treatment. 

Treatment. — In  the  presence  of  evidences  of  syphilis,  tuber- 
culosis, rheumatism,  etc.,  constitutional  treatment  should  be 
prescribed  in  addition  to  local  measures.  In  all  cases,  the 
general  health  should  receive  any  necessary  treatment. 

Cleanliness  of  the  nasal  passages  is  of  the  utmost  importance 


5IO  CHRONIC    NASAL    CATARRH. 

and  is  best  effected  by  the  post-nasal  syringe,  with  either  simple 
or  medicated  tepid  waters,  or  a  cleansing  solution,  such  as 
Dobell's: 

I^.      Acidi  carbolici gr.  j  .065  gm. 

Sodii  bicarbonat., 

Sodii  borat aa  gr.  v  aa        .  3       gm. 

Glycerini f3i  4.  c.c. 

Aquae f5j  30.         c.c. 

M.  S. — Use  as  a  spray  or  with  a  proper  vSyringe. 

Or,  the  following  combination  of  Sajous — 
J\.      Sodii  bicarb., 

Sodii  bibor aa  gr.  viij        aa        .52  gm. 

Fluidextracti  pinus  canad.  ttlxv  i  .        c.c. 

Glycerini f  3ij  8 .        c.c. 

Aquae q.  s.  ad  f  oiv     q.s.adi2o .       c.c. 

M.  S. — Apply  with  atomizer  three  or  four  times  daily. 

After  which,  decided  benefit  follows  the  use  of  the  following: 

I^.      Pulv.  sanguinarias 5j  4.     gra. 

Acid,  tannici gr.v  .3  gm, 

Pulv.  camphorae oj  4.     gm. 

Bismuth,  subnit oij  8 .     gm. 

M.  S. — To  be  used  by  insufflation  or  as  a  snuff  every  three 

or  four  hours. 

Ilf.      Ammonii  chloridi oj  4.  gm. 

Glycerini f  5ij  8  .  c.c. 

Fluidextracti  pinus  canad  f  5j  30.  c.c. 

Aquae  destil q.  s.  ad  f  5ij       q-  s.    ad   60.  c.c. 

M.  S. — Five  or  10  drops,  dropped  into  each  nostril  two  or 
three  times  a  day,  or  applied  with  a  camel' s-hair  brush. 

Or  the  following   pleasant  mixture  may  be  applied  to  each 
nostril : 

I^.      Tine L.  benzoin f3iv  15.     c.c. 

Tinct.  guaiaci f  3  j  4  .     c.c. 

Chloroformi tt^x  .  6  c.c. 

Tinct.  myrrh foss  2.     c.c. 

01.  amygd n\v  .3  c.c. 

M.  S. — A  few  drops  in  each  nostril  once  a  day. 


ACUTE    CATARRHAL    LARYNGITIS.  51I 


Frequently  the  mucous  membrane  becomes  greatly  hyper- 
trophied  and  requires  the  use  of  the  galvanocautery  or  caustics 
to  remove  the  obstruction.  Polyps  may  also  form  and  should 
be  removed  by  the  snare.  In  atrophic  rhinitis  or  ozena  diffi- 
culty is  often  encountered  in  removing  the  crusts  before  making 
any  local  application.  This  may  be  overcome  by  the  use  of 
peroxid  of  hydrogen  or  ordinary  coal-oil  and  generous  douching 
with  an  alkaline  solution.  Oily  sprays,  such  as  liquid  vaselin, 
albolene,  with  or  without  the  addition  of  menthol,  eucalyptol, 
or  thymol,  may  then  be  employed.  Boroglycerin  is  also  of 
great  value. 


DISEASES  OF  THE  LARYNX. 

ACUTE  CATARRHAL  LARYNGITIS. 

Synonyms. — Catarrhal  laryngitis;   "sore  throat." 
Definition. — An  acute  catarrhal  inflammation  of  the  mucous 

membrane  of  the  larynx;  characterized  by  feverishness,  dimin- 
ished or  suppressed  voice,  painful  deglutition,  and  more  or  less 
difficulty  of  respiration. 

Causes. — Atmospheric  changes,  cold  draughts  of  air  directly 
inhaled,  or  undue  exposure  of  any  or  all  parts  of  the  body  to  the 
same,  cold  and  wet  feet,  inhalation  of  dust  or  irritating  vapors, 
such  as  gases,  smoke,  ammonia,  etc.,  prolonged  efforts  at  sing- 
ing or  speaking  in  public,  especially  when  under  difficulties, 
impacted  foreign  body,  and  infectious  fevers,  are  the  most 
common  causes.  It  may  also  be  associated  with  catarrh  of  the 
nose,  pharynx,  trachea,  or  bronchi.  In  children  it  may  be 
due  to  violent  fits  of  crying.  Some  people  have  a  predisposition 
to  catarrhal  laryngitis. 

Pathologic  Anatomy. — The  mucous  membrane  is  congested 
and  swollen,  and- the  secretion  greatly  diminished.  In  many 
cases   only   portions   of   the   laryngeal   mucous   membrane    are 


512  ACUTE    CATARRHAL    LARYNGITIS. 

involved.  The  inflamed  membrane  returns  to  its  normal  condi- 
tion very  shortly,  and  the  secretion  is  then  increased. 

Symptoms. — The  attack  begins  rather  suddenly  with  a  feeling 
of  dryness,  rawness,  and  tickling,  referred  to  the  larynx  with  the 
sensation  of  the  presence  of  a  foreign  body  in  the  throat,  and 
with  hoarseness  and  a  disposition  to  cough.  Deglutition  causes 
pain  by  the  upward  movement  of  the  larynx  and  by  the  pressure 
of  the  food  on  the  larynx  as  it  passes  along  the  gullet.  Attempts 
at  speaking  are  attended  with  more  or  less  distress  and  the  lar- 
ynx is  tender  on  pressure.  Coughing,  of  a  noisy,  harsh,  hoarse, 
or  toneless  character  is  present  from  the  onset,  and  is  attended 
by  a  sensation  of  scratching  in  the  larynx.  The  first  day  or  two 
there  is  scanty  expectoration,  but  in  a  short  time  the  secretion 
is  increased,  giving  the  cough  a  loose  character.  In  the  early 
stages  the  sputa  may  be  slightly  streaked  with  blood.  Rarely 
a  hemorrhage  occurs  from  the  mucous  membrane  of  the  larynx. 
The  voice  is  at  first  decidedly  hoarse,  soon  followed  by  com- 
plete aphonia.  The  respiration  is  but  slightly,  if  at  all,  affected 
in  adults,  except  when  there  is  marked  edema.  There  may  be 
more  or  less  febrile  reaction.  In  children  the  onset  is  attended 
with  fever,  white  coated  tongue,  frequent,  tense  pulse,  hot  skin 
and  flushed  face,  embarrassed  respiration,  the  voice  hoarse 
and  whispering,  with  harsh,  ringing,  croupy  cough  and  great 
restlessness.  During  the  night  the  child  is  subject  to  suffoca- 
tive attacks  (laryngismus  stridulus).  Similar  paroxysms 
may  also  occur  in  highly  sensitive  adults. 

Laryngoscopic  Appearances. — These  vary  with  the  severity 
of  the  attack  and  the  stage  of  the  inspection.  In  mild  cases,  at 
an  early  period,  the  mucous  membrane  presents  a  bright  red 
appearance.  Severe  cases  present,  in  addition  to  the  bright 
redness,  swelling  of  the  mucous  membrane  to  such  an  extent 
at  times  as  to  conceal  the  vocal  cords,  they  appearing  only  as 
slender  threads  of  a  reddish  tint.  x\t  times  the  mucous  mem- 
brane presents  the  appearance  of  erosions  or  ulcerations,  due 
to  the  desquamation  of  the  epithelium. 

Prognosis. — Simple  catarrhal  laryngitis  never  terminates 
fatally  and  runs  its  course  usually  in  one  week,  but  may  be 


ACUTE    CATARRHAL    LARYNGITIS.  513 

prolonged  for  two  or  three  weeks  in  severe  cases.  When  edema 
is  present  in  addition,  there  is  always  danger  from  asphyxia. 

Treatment. — The  patient  should  be  confined  to  an  apartment 
of  uniform  temperature,  the  air  being  kept  moist  by  the  vapor 
of  boiling  water.  Attempts  to  use  the  voice  should  be  dis- 
countenanced. At  the  very  beginning  of  an  attack  the  feet 
should  be  placed  in  a  hot  mustard  foot-bath  and  either  a  saline 
or  mercurial  purgative  should  be  administered.  Prompt  action 
of  the  skin  at  this  stage  will  frequently  aid  in  shortening  the 
attack.  For  this  purpose  Dover's  powder,  gr.  iii  (0.2  gm.), 
combined  with  potassium  nitrate,  gr.  iii  (0.2  gm.),  should  be 
administered  every  three  or  four  hours.  If  there  is  much 
febrile  reaction,  benefit  will  be  obtained  from  the  use  of  tincture 
of  aconite,  ttlv  (0.3  c.c),  every  half-hour  until  5  doses  are 
taken,  after  which  it  should  be  given  every  hour  or  two*  com- 
bined with  tincture  of  opium,  nxi  to  v  (0.06  to  0.3  c.c).  Dia- 
phoresis is  also  of  value  and  may  be  obtained  by  the  administra- 
tion of  antimony  and  potassium  tartrate,  gr.  1/20  to  1/30 
(0.003  "to  0.002  gm.),  every  hour,  or  by  the  hypodermic  injection 
of  pilocarpin  hydrochlorid,  gr.  1/3  (0.022  gm.). 

For  children,  several  doses  of  the  following  should  be  given  a 
couple  of  hours  apart,  until  Ihe  bowels  are  freel}^  moved: 

I^.     Hydrarg5a-ichl0ridimitis.gr.  1/8  .  008  gm. 

Pulvis  ipecacuanha gr.  1/8  .008  gm. 

Sacch.  lactis gr.  ij  .13     gm. 

M.  S. — One  dose. 

To  be  followed  by — 

I^.     Potassii  citrat 5iv  5.3  gm. 

Tinct.  aconiti ni^v  i  •  c.c. 

Tinct.  opii  camphorat.  .  .    f  oij  to  iv        8.  to  15.  c.c. 

.  Syr.  scillae f  oij  8  .  c.c. 

Sjnr.  tolu q.  s.  ad  f  §iij  q.s.  ad  90  .  c.c. 

M.  S. — One  teaspoonful  every  two  hours. 

If  a  tendency  to  spasm  of  the  glottis  obtains,  full  doses  of  the 
bromids  should  be  administered  at  once. 
33 


514  EDEMATOUS    LARYNGITIS. 

Inhalations  from  the  onset  are  not  only  soothing,  but  curative, 
in  their  actions.     The  following  is  recommended: 

I^.     Tinct.  benzoin  comp f5j  to  ij  4  to  8  c.c. 

Aquae  bull Oj  480.  c.c. 

M.  S. — Inhale  hourly. 

The  local  application  of  cocain  is  of  great  benefit.  A  hot  pack 
should  also  be  kept  constantly  wrapped  about  the  throat,  and 
if  its  application  is  preceded  by  the  temporary  use  of  a  weak 
mustard  plaster,  the  relief   afforded  is  more  rapidly  obtained. 

Attacks  of  acute  laryngitis  following  efforts  at  singing  or 
speaking  in  public  are  wonderfully  benefited  by  the  use  of 
dilute  nitric  acid,  rq^ii  to  v  (0.12  to  0.3  c.c),  every  hour;  oratropin 
sulphate,  gr.  1/300  (0.00022  gm.),  every  hour  for  several  doses. 

The  onset  of  edema  calls  for  cold  applications,  scarification, 
astringent  applications,  and,  if  asphyxia  threatens,  tracheotomy. 

EDEMATOUS  LARYNGITIS. 

Synonym. — Edema  of  the  glottis. 

Definition. — An  acute  inflammation  of  the  mucous  membrane 
of  the  larynx  and  that  about  the  glottis,  with  an  infiltration  of 
the  areolar  tissues  by  a  serous,  sero-purulent  or  purulent  fluid; 
characterized  by  obstructed  or  stridulous  breathing  and  dys- 
phonia  or  aphonia.. 

Causes. — It  may  occur  in  the  course  of  acute  laryngitis,  sup- 
puration in  or  about  the  throat  or  tonsils,  facial  erysipelas, 
scarlatina,  small-pox,  diphtheria,  Bright's  disease,  or  urticaria. 
Burns,  scalds,  swallowing  of  caustic  substances,  and  ulcerative 
affections  such  as  tuberculosis  and  syphilis  may  produce  it.  It 
is  rare  in  children,  most  cases  occurring  in  men  between  the 
ages  of  twenty  and  thirty-five  years. 

Pathologic  Anatomy. — Infiltration  into  the  loose  connective 
tissue  of  the  ary-epiglottic  folds,  the  glosso-epiglottic  ligament, 
the  base  of  the  epiglottis,  and  the  interarytenoid  space  is  the 
principal  change.  If  the  true  vocal  cords  are  inflamed,  their 
color  changes,  and  instead  of  appearing  white,  glistening  and 


EDEMATOUS    LARYNGITIS.  515 

brilliant,  they  are  dull,  grayish-red,  or  violet-red  in  patches.  If 
the  swelling  be  the  result  of  purulent  infiltration,  the  parts 
present  a  deeply  congested  color,  with  here  and  there  spots  of  a 
yellowish  hue.  Serous  infiltration,  sufTficient  to  cause  fatal 
edema,  disappears  with  death,  leaving  but  slight  traces  to  ac- 
count for  the  formidable  symptoms. 

Symptoms. — The  onset  is  much  the  same  as  a  simple  catarrhal 
laryngitis  with  a  gradually  increasing  impediment  to  the  respi- 
ration. The  patient  experiences  the  sensation  of  a  foreign  body 
in  the  throat,  and  after  a  short  time  difficulty  of  breathing,  which 
ultimately  threatens  sufTocation.  The  deglutition  is  rendered 
difficult  owing  to  the  swelling  of  the  epiglottis;  the  voice,  at 
first  muffled,  gradually  becomes  weaker  and  weaker,  until  finally 
it  is  almost  extinct;  the  cough  at  first  is  dry  and  harsh,  but  as  the 
infiltration  increases  it  becomes  stridulous  and  suppressed;  there 
is  no  expectoration,  except  after  great  effort  to  clear  the  throat, 
when  a  little  frothy  mucus  is  raised.  The  difficulty  of  res- 
piration, as  the  disease  progresses,  becomes  greater  and  greater, 
and  the  paroxysms  of  impending  suffocation  more  frequent.  The 
inspiration  is  accompanied  by  a  whistling  sound  characteristic 
of  the  narrow  condition  of  the  glottis;  the  patient  sits  up  in  bed, 
his  mouth  open,  gasping  for  breath,  his  eyes  protruding,  the 
whole  body  trembling  with  intense  convulsive  movements,  and 
after  a  time  a  general  cyanosis  commences,  the  face  assuming  a 
bluish  hue,  all  these  symptoms  continuing  for  a  few  moments, 
when  slight  relief  occurs,  to  be  again  followed  by  another  par- 
oxysm, in  one  of  which,  if  nature  or  art  does  not  afford  prompt 
relief,  death  occurs  from  asphyxia. 

A  physical  examination  of  the  parts  may  be  made  by  gently 
passing  the  finger  into  the  throat,  when  the  epiglottis  may  be 
felt  very  much  thickened,  and  the  ary-epiglottic  folds  may  have 
attained  such  tumefaction  as  to  convey  to  the  finger  an  impres- 
sion similar  to  that  which  is  given  by  touching  the  tonsils. 

Laryngoscopic  Appearance. — The  mucus  membrane  has  a 
bright  red  appearance.  The  epiglottis  has  the  appearance  of  a 
semitransparent,  roll-like  body,  or  it  is  often  merely  erect  and 
tense.     It  is  this  condition  of  the  epiglottis  which  explains  the 


5l6  SPASMODIC    LARYNGITIS. 

pain  and  diffictilty  in  deglutition.  Rarely  the  vocal  cords  are 
infiltrated. 

Diagnosis. — Any  disease  which  gives  rise  to  dyspnea  may 
simulate  edematous  laryngitis,  but  the  history  of  the  case,  to- 
gether with  a  laryngoscopic  examination,  will  generally  furnish 
conclusive  evidence  of  the  nature  of  the  malady. 

Prognosis. — The  outlook  is  unfavorable ;  about  one-half  of  the 
cases  terminate  fatally.  If  early  and  vigorous  treatment  be  in- 
stituted recovery  is  possible,  but  without  it  asphyxia  and  death 
are  the  inevitable  results.  Even  after  the  local  obstruction  has 
been  removed,  the  patient  is  liable  to  perish  subsequently  from 
exhaustion,  blood-poisoning,  or  pulmonic  complications.  The 
duration  varies  from  a  few  hours  to  several  days. 

Treatment. — Prompt  local  treatment  is  necessary  to  relieve 
the  obstruction.  Leeches  placed  externally  over  the  larnyx 
may  be  of  value  in  reducing  the  edema  in  mild  cases.  The  per- 
sistent use  of  ice-pellets  early  in  the  attack,  swallowed  or  held 
far  back  in  the  mouth  until  dissolved,  is  recommended  by 
Niemeyer;  or  the  Leiter  coil  may  be  used.  The  hypodermic  in- 
jection of  pilocarpin  hydrochlorid,  gr.  1/3  (0.022  gm.),  until 
free  salivation  and  diaphoresis  are  produced,  is  of  great  value, 
care  being  taken  to  avoid  cardiac  depression. 

Relief  may  be  afforded  in  the  early  stage  by  scarification  of  the 
edematous  tissues,  guiding  the  instrument  by  the  index  finger  of 
the  opposite  hand.  If  the  various  measures  already  mentioned 
fail,  tracheotomy  or  intubation  is  indicated. 

In  all  cases  food  and  stimulants  should  be  administered,  pref- 
erably by  the  rectum,  as  swallowing  is  difficult  and  serves  to  ag- 
gravate the  condition.  If  the  infiltration  becomes  purulent, 
quinin  sulphate,  gr.  v  (0.3  gm.)  every  four  hours  is  indicated  in 
addition. 

SPASMODIC  LARYNGITIS. 

Synonyms. — Spasmodic  croup;  false  croup;  catarrhal  croup. 
Definition. — A  catarrhal  inflammation  of  the   mucous  mem- 
brane of  the  larnyx,  associated  with  temporary  spasmodic  con- 


SPASMODIC    LARYNGITIS.  517 

traction  of  the  glottis ;   characterized  by  paroxysmal  coughing, 
difficulty  of  breathing,  and  attacks  of  threatening  suffocation. 

Causes. — Atmospheric  changes  or  "taking  cold,"  excesses  in 
eating  and  drinking,  excitement,  and  violent  emotion,  are  given 
as  causes. 

Pathologic  Anatomy. — Congestion  of  the  mucous  membrane 
of  the  larynx,  with  slight  swelling  and  deficient  secretion,  are 
the  only  changes  that  have  thus  far  been  noted. 

Symptoms. — The  attack  occurs  chiefly  during  the  night,  the 
child  on  retiring  having  either  its  usual  health,  or  perhaps  being 
a  little  feverish.  After  several  hours  of  sleep  the  child  is  sud- 
denly awakened  by  a  paroxysm  of  suffocation,  and  a  dry,  harsh, 
ringing  cough.  After  half  an  hour  or  an  hour  or  two  the  breath- 
ing becomes  easier,  and  the  cough  less  "croupy";  the  skin  is 
covered  with  more  or  less  perspiration,  and  the  child  falls 
asleep.  The  next  day  there  is  present  cough  of  a  loose  character, 
the  respiration  being  about  normal.  If  no  treatment  be  insti- 
tuted, the  same  phenomena  occur  on  the  second  night,  the  child 
being  apparently  well  during  the  second  day,  the  cough  being 
less  in  amount;  phenomena  of  a  similar  character,  but  of  much 
less  severity,  are  present  the  third  night,  after  which  the  dis- 
ease usually  disappears. 

Diagnosis. — The  history,  course,  and  absence  of  marked 
constitutional  disturbances  will  distinguish  this  affection 
from,  diphtheria;  in  the  latter  a  bacteriological  examination 
will  show  the  Klebs-Loefffer  bacilli.  In  laryngismus  stridulus, 
there  is  a  history  of  rachitis,  and  an  absence  of  catarrhal 
symptoms. 

Prognosis. — Spasmodic  or  false  croup  always  terminates 
favorably. 

Treatment. — During  the  paroxysm,  the  child  should  at  once 
be  placed  in  a  hot  bath  and  hot  or  cold  compresses  should  be 
applied  to  the  throat.  These  measures  should  be  preceded  or 
followed  b}^  the  administration  of  a  mild  emetic.  The  syrup 
or  wine  of  ipecac,  in  doses  of  3ss  to  3i  (2  to  4  c.c),  every  few 
minutes  until  vomiting  is  produced,  is  very  efficient.  Bartholow 
recommends  turpeth  mineral,- gr.   i  to  iii   (0.065   to  0.2   gm.); 


5l8  LARYNGISMUS    STRIDULUS. 

Da  Costa  suggests  the  cautious  use  of  apomorphin  hydrochlorid, 
gr.  i/io  (0.006  gm.),  hypodermically.  The  late  Charles  D. 
Meigs  always  used  powdered  alum  alone  or  with  syrup  of  ipecac. 
Powdered  alum  is  of  great  value  in  teaspoonful  doses,  adminis- 
tered in  honey  or  molasses  and  repeated  in  fifteen  minutes, 
until  vomiting  is  produced.  In  the  absence  of  these  means  of 
inducing  emesis,  irritation- of  the  fauces  by  a  feather  or  by  the 
finger,  will  bring  about  the  desired  result.  In  very  severe 
paroxysms  the  inhalation  of  chloroform  may  be  necessary. 

As  soon  as  the  paroxysm  has  been  broken,  a  laxative  should 
be  given.  Calomel,  gr.  ii  (0.13  gm.),  and  sodium  bicarbonate, 
gr.  iii  (0.2  gm.),  should  be  administered  and  followed  in  six  or 
eight  hours  by  a  dose  of  castor  oil  or  magnesia.  During  the 
intervals  between  the  paroxysms,  small  doses,  nxv  to  x  (0.33  to 
0.66  C.C.),  of  the  syrup  or  wine  of  ipecac,  or  the  following  should 
be  given: 

I^.      Tincturae  aconiti rrLXxiv  i .  5  c.c. 

Syr.  ipecacuanhae fjiss  6.     c.c. 

Tincturae  opii  camphorat  f  oiij  12-.     c.c. 

Liquor,  potassii  citratis.adf  Biij  ad  90.     c.c. 

M.  S.  — One  teaspoonful  every  hour  or  two. 


LARYNGISMUS  STRIDULUS. 

Synonyms. — Spasm  of  the  glottis;  spasmodic  laryngitis; 
thymic  asthma;  tetany;  child-crowing 

Definition. — A  spasm  of  the  muscles  of  the  larynx  innervated 
by  the  inferior  or  recurrent  laryngeal  nerves;  characterized  by  a 
sudden  development  of  dyspnea  and  deficient  oxygenation  of 
the  blood. 

Causes. — The  affection  is  most  common  in  young  children,  as 
the  result  of  reflex  irritation  such  as  gastrointestinal  troubles, 
(such  as  worms,  overloading  the  stomach),  teething,  la,ryngitis, 
scrofula,  fright,  and  rachitis.  It  occasionally  occurs  in  adults. 
It  may  be  hereditary.  Many  observers  believe  it  to  be  a  form 
of  tetany. 


LARYNGISMUS    STRIDULUS.  519 

Pathology. — Death  rarely  occurs,  and  in  consequence  the 
morbid  anatomy  is  as  yet  undetermined.  The  mechanism  con- 
sists in  an  irritation  of  the  superior  laryngeal  nerve — the  affe- 
rent nerve — whose  function  is  to  supply  the  mucous  lining  of  the 
larynx  with  sensibility,  whence  is  reflected  through  the  inferior 
laryngeal  nerve — the  efferent  nerve — the  motor  influence  result- 
ing in  the  spasm  of  the  laryngeal  muscles. 

Symptoms. — The  spasm  of  the  laryngeal  muscles  is  of  sudden 
onset,  and  usually  after  nightfall.  The  child  may  have  been  in 
perfect  health,  to  all  appearances,  on  retiring,  or  it  may  have 
shown  symptoms  of  catarrh  of  the  upper  air  passages,  or  been 
suffering  from  gastrointestinal  or  dental  irritation.  The  child 
awakens  suddenly,  coughing  in  a  metallic,  resonant  tone — the 
croupy  cough — and  with  great  dyspnea,  with  loud,  crowing, 
stridulous  inspirations,  the  result  of  narrowing  of  the  larynx 
from  spasm,  and  with  wheezy,  stridulous  expirations.  The 
entrance  of  air  is  so  greatly  obstructed  that  all  the  accessory 
muscles  of  respiration  are  called  into  use ;  the  lips  and  finger  nails 
become  blue,  the  surface  cold,  the  countenance  anxious,  and  the 
inferior  portion  of  the  chest  is  drawn  in,  instead  of  being 
expanded,  during  inspiration.  General  convulsions  occur  at 
times,  during  a  paroxysm,  also  strabismus,  and  involuntary 
discharges  of  the  feces  and  the  urine. 

The  paroxysm  continues  from  half  an  hour  to  an  hour  or 
more,  to  return  after  a  few  hours'  sleep  or  during  the  follow- 
ing night;  the  cough,  during  the  day,  having  the  croupy 
character. 

Diagnosis. — The  non-febrile  and  distinctly  intermittent  char- 
acter of  the  affection  with  its  peculiar  crowing  inspiration  differ- 
entiates it  from  other  laryngeal  conditions.  From  diphtheria  it 
may  be  recognized  by  the  history,  by  the  absence  of  membrane, 
and  absence  of  marked  local  inflammation. 

Prognosis. — Favorable.  Death  from  suffocation  during  the 
paroxysm  may  occur  in  very  young  and  debilitated  children, 
but  it  is  a  very  rare  termination. 

Treatment. — ^The  inhalation  of  a  few  drops  of  chloroform  or 
amyl  nitrite  will  serve  to  relieve  the  paroxysm.      Nitroglycerin 


520  CHRONIC    LARYNGITIS. 

in  small  but  frequently  repeated  doses,  or  the  following  com- 
bination, is  a  valuable  antispasmodic: 

I^.     Potassii  bromid 5ii  8.  gm. 

Chloral gr.  xvxij         2.  gm. 

Syr.  aurantii  c6rt foj  30.  c.c. 

Aqu^  menth.  pip f§j  30.  c.c. 

M.  S. — One  teaspoonful  every  half  hour. 

After  the  attacks  have  been  suspended,  the  tendency  to  recur- 
rence is  prevented  by  the  continued  use  of  potassium  bromid  in 
moderate  doses.  Cases  due  to  indigestion  are  greatly  relieved 
during  the  paroxysm  by  the  administration  of  an  emetic. 

Locally,  the  hot  pack,  alternating  with  the  cold  pack,  should 
be  applied  to  the  throat  continuously.  The  vapor  of  boiling 
water  should  be  inhaled  in  addition. 

After  the  attack  has  subsided  calomel  followed  by  magnesia 
or  castor  oil  should  be  given.  All  farinaceous  substances  should 
be  eliminated  from  the  diet,  and  tonics  should  be  administered. 
The  rachitic  factor  in  the  disease  should  also  receive  attention. 

CHRONIC  LARYNGITIS. 

Causes. — Simple  chronic  catarrhal  inflammation  of  the  larynx 
may  be  due  to  repeated  acute  attacks,  or  may  follow  persistence 
of  the  same  causes  that  produce  the  acute  variety  such  as  over- 
use of  the  voice,  irritation  of  smoke,  vapors,  etc.,  and  excessive 
use  of  alcohol  and  tobacco. 

Pathologic  Anatomy.- — Redness  and  swelling  are  present  and 
there  is  more  or  less  thickening  of  the  parts  concerned  in  the  pro- 
duction of  the  voice.  Relaxation  of  one  or  both  vocal  cords 
may  be  observed.  Superficial  erosions,  distention  of  the  folli- 
cles, and  villous  outgrowths  on  the  cords  may  be  present. 

Symptoms. — Hoarseness  and  discomfort  in  the  use  of  the 
voice  are  the  most  prominent  symptoms.  Aphonia  may  occur. 
There  is  a  great  tendency  to  cough,  but  expectoration  is  scanty 
and  mucoid  in  character.  Inspection  reveals  swelling,  conges- 
tion, and  a  granular  appearance  of  the  larynx. 


SYPHILITIC    LARYNGITIS.  521 

Prognosis. — Owing  to  the  persistence  of  the  causes  and  the 
inability  of  the  patient  to  co-operate  in  the  treatment,  complete 
recovery  is  not  common.  Under  more  favorable  circumstances, 
the  prognosis  is  fairly  good. 

Treatment. — The  various  causes  should  be  ascertained  and 
promptly  removed.  Smoking,  and  drinking  of  alcoholic  bever- 
ages should  be  prohibited  and  the  patient  taught  to  properly 
use  the  voice.  Systematic  exercises,  fresh  air,  and  tonic  treat- 
ment are  indicated.  Associated  nasal  and  pharyngeal  afTections 
should  receive  attention.  Astringent  sprays  such  as  alum 
(3  per  cent.)  solution,  tannin  solution  (i  to  2  percent.),  sulphate 
of  zinc  (3  per  cent,  solution),  etc.,  are  of  great  value  and  should 
be  preceded  by  cleansing  of  the  pharynx  and  larynx  with 
Dobell's  solution  or  some  similar  alkaline  mixture.  The  inhala- 
tion of  steam  charged  with  some  volatile  substance  such  as 
benzoin,  benzoic  acid,  or  cubebs  is  also  beneficial.  Troches 
containing  benzoic  acid  (1/2  gr.),  cubebs  (i  to  2  gr.),  ammon- 
ium chlorid  (3  to  5  gr.),  potassium  chlorate  and  borax  (21/2  gr. 
of  each),  etc.,  are  productive  of  good  results.  Insufflation  of 
dry  powders  such  as  starch  and  tannic  acid  (equal  parts),  alum 
and  starch  (equal  parts),  iodoform,  and  similar  substances,  into 
the  larynx  often  affords  relief.  The  direct  application  of  silver 
nitrate  solution  (10  to  15  gr.  to  the  ounce),  or  a  solution  of 
resorcin  (10  per  cent.)  in  glycerin  to  the  diseased  areas  is  effica- 
cious in  many  cases. 


SYPHILITIC  LARYNGITIS. 

Syphilis  of  larynx  may  manifest  itself  as  a  diffuse  non-dis- 
tinctive catarrhal  inflammation,  moist  papules  or  "mucous 
patches,"  or  ulceration  (gumma).  The  mucous  patches  may 
be  found  on  thfe  epiglottis,  in  the  laryngeal  wall,  and  on  the 
epiglottidean  folds,  but  rarely  on  the  vocal  cords.  They  are 
seldom  replaced  by  ulceration.  Gumma  of  the  larynx  is  fol- 
lowed by  circular,  deep,  and  sharply  marginated  ulcers.  Rapid 
necrosis  of  the  cartilages  is  common,  and  the  resulting  cicatrix 


52  2  TUBERCULOUS    LARYNGITIS. 

may    give    rise    to    stenosis.     The    symptoms    are    hoarseness, 
cough,  more  or  less  loss  of  voice,  and  pain  on  deglutition. 

Diagnosis. — The  history,  the  rapidly  spreading  circumscribed 
ulcers,  and  the  results  of  specific  treatment  aid  greatly  in  distin- 
guishing this  affection  from  tubercular  laryngitis  in  which  there  '* 
are  manifestations  of  tuberculosis  elsewhere  in  the  body. 

Prognosis. — Under  proper  treatment  the  ulcers  heal  rapidly, 
but  the  resulting  cicatrices  may  permanently  impair  the  voice. 

Treatment. — Mercury  and  the  iodids  should  be  administered 
in  full  doses  to  the  point  of  tolerance.  Locally,  astringent  and 
alkaline  sprays,  together  with  applications  of  silver  nitrate  (solid 
stick  or  in  solution)  or  chromic  acid  solution  (12.5  per  cent.)  to 
the  ulcers,  are  of  great  value.  Insufflation  of  iodoform  is  also 
of  value.  The  galvanocautery  directly  applied  to  the  ulcers  is 
also  recommended.  Zinc  chlorid,  copper  sulphate,  and  similar 
astringents  may  be  used  with  benefit. 


TUBERCULOUS  LARYNGITIS. 

Synonyms. — Laryngeal  phthisis;  throat  consumption. 

Definition. — A  tuberculous  inflammation  of  the  larynx,  char- 
acterized by  ulceration,  pain  on  deglutition,  cough,  weakness  of 
voice,  hectic  fever,  and  progressive  emaciation. 

Cause. — The  affection  is  produced  by  the  tubercle  bacillus, 
and  may  be  primary,  but  is  generally  secondary  to  some  other 
focus  of  tuberculosis,  usually  in  the  lungs. 

Pathologic  Anatomy. — All  laryngeal  affections  in  the  course 
of  phthisis  are  not  necessarily  tubercular.  True  tubercular 
laryngitis  begins  with  redness  of  the  mucous  membrane,  show- 
ing scattered  tubercles.  The  tubercles  show  a  strong  tendency 
to  cluster,  then  soften,  leaving  shallow,  irregular  ulcers.  The 
parts  chiefly  affected  are  the  posterior  portion  of  the  vocal  cords, 
and  the  epiglottis.  The  ulcers  are  covered  with  a  grayish 
exudate.  The  mucous  tissue  round  about  the  ulcers  is  thick- 
ened. The  ulcers  may,  and  generally  do,  erode  the  true  vocal 
cords,    often    entirely    destroying    them.     The    ulcers    slowly 


TUBERCULOUS    LARYNGITIS. 


The 


extend  in  all  directions,  destroying  the  tissues  attacked 
epiglottis  may  be  entirely  destroyed. 

Laryngeal  tuberculosis  and  syphilis  may  be  differentiated  as 
follows : 


Tuberculosis, 


Syphilis. 


Pain  severe  on  deglutition. 

Ulcerates  slowly. 

Usually  first  appears  as  small 
spots  or  nodules  which  are  rap- 
idly followed  by  great  edema. 

Ulcers  extend  laterally  but  not 
deeply. 

Mucous  membrane  usually  pale. 

Health     impaired     previous     t  o 

laryngeal  involvement. 
Previous  or  coincident  pulmonary 

trouble  common. 
lodids  have  no  influence. 


Pain  usually  slight. 

Ulcerates  rapidly. 

Is  rarely  seen  in  stage  of  indura- 
tion, the  first  evidence  being  a 
clear-cut,  deep  ulcer. 

Ulcers  extend  deeply,  often  in- 
volving cartilage. 

Mucous  membrane  hyperemic, 
injected. 

General  health  unimpaired. 

Frequently  evidence  of  syphilitic 

disease  in  other  tissues. 
Readily  improves  under  iodids. 


{From  Gibb's  table,  as  modified  by  Coakley.) 

Symptoms. — The  first  symptom  is  a  change  in  the  voice — 
huskiness ;  this,  associated  with  symptoms  of  ill-health,  is  alw^ays 
a  warning  to  the  physician.  The  husky  voice  may  proceed 
until  it  is  but  a  painful  whisper.  Cough  of  an  irritating,  pain- 
ful character  is  present,  associated  with  slight  expectoration. 
Painful  and  difficult  deglutition  (dysphagia)  is  a  very  constant 
and  distressing  symptom.  There  is  the  remitting  fever  so 
characteristic  of  tuberculosis,  with  night-sweats,  loss  of  appetite, 
loss  of  flesh,  and  insomnia. 

Laryngoscopic  examination  reveals  the  characteristic  broad, 
shallow,  irregular,  grayish  ulcers,  with  the  thickened  surround- 
ing mucous  membrane.  The  vocal  cords  show  infiltration  and 
thickening  or  ulceration. 


524  ACUTE    BRONCHITIS. 

Diagnosis. — While  the  broad, .  shallow,  irregular  ulcers  are 
fairly  characteristic  of  this  disease,  no  positive  diagnosis  can  be 
made  until  the  sputum  is  examined  and  tubercle  bacilli  found 
therein. 

Prognosis. — Unfavorable. 

Treatment. — The  general  treatment  is  that  of  tuberculosis  else- 
where in  the  body.  The  diet  should  be  liquid  and  concentrated, 
on  account  of  the  distress  and  difficulty  in  swallowing.  Much 
can  be  done  by  local  treatment  to  render  the  patient  comfort- 
able. The  application  of  lactic  acid  (20,  40,  or  60  per  cent, 
solution)  to  the  larynx  is  very  beneficial.  Cocain  similarly 
employed  is  also  of  value  in  relieving  the  pain  and  dysphagia. 
Hydrogen  peroxid,  silver  nitrate,  and  menthol  may  be  used 
with  good  results.  Curetting  of  the  ulcers  and  applying  iodo- 
form in  emulsion  or  with  morphin  sulphate  has  been  practised 
with  benefit.  Alkaline  washes  and  sedative  inhalations  are 
also  recommended. 

DISEASES  OF  THE  BRONCHIAL  TUBES. 
ACUTE  BRONCHITIS. 

Synonyms.-^— Bronchial  catarrh;  acute  bronchial  catarrh; 
"cold  on  the  chest." 

Definition. — An  acute  catarrhal  inflammation  of  the  bron- 
chial tubes  of  the  larger,  middle,  and  third  size;  characterized 
by  fever,  substernal  pain,  a  feeling  of  thoracic  constriction, 
oppression  in  breathing,  and  at  first  scanty,  followed  by  more 
or  less  profuse,  expectoration. 

Causes. — It  is  most  frequent  in  childhood,  especially  during 
the  period  of  dentition,  when  there  exists  a  strong  tendency 
to  catarrh  of  the  mucous  membranes  in  general  and  of  the 
bronchi  in  particular.  In  old  age  the  predisposition  again 
returns.  Inhalation  of  irritants  such  as  dust,  smoke,  and  air 
too  hot  or  too  cold,  is  also  a  common  cause.  The  affection  is 
more  common  in  climates  characterized  by  considerable  moisture 
of  the  atmosphere,  combined  with  a  low  temperature,  and  espe- 
cially where  there  are  sudden  and  marked  variations.     Chronic 


ACUTE    BRONCHITIS.  525 

heart  disease,  uric  acid  diathesis,  and  exposure  to  cold  and  wet 
are  potent  etiologic  factors.  It  accompanies  the  infectious 
fevers  such  as  typhoid  fever,  influenza,  whooping  cough,  and 
measles.  The  exciting  cause  is  a  microorganism;  staphyl- 
ococci, streptococci,  or  pneumococci  may  be  found  in  the 
sputum. 

Pathologic  Anatomy.— The  mucous  membrane  of  the  bron- 
chial tubes  is  at  first  congested,  swollen,  and  edematous.  Se- 
cretion is  diminished.  Later,  there  are  increased  secretion  and 
overgrowth  and  desquamation  of  the  epithelium  together  with 
proliferation  of  young  cells  and.  leukocytic  infiltration.  The 
expectoration  is  then  of  a  yellowish  color  (muco-purulent).  In 
the  early  stage  the  scant  expectoration  may  be  streaked  with 
blood  due  to  rupture  of  the  distended  capillaries. 

In  cases  of  bronchitis  following  the  exanthemata,  or  in  scrofu- 
lous patients,  the  bronchial  glands  participate  in  the  inflamma- 
tion, becoming  hyperemic,  swollen,  and  filled  with  secretion, 
and  not  infrequently  the  glandular  elements  undergo  a  hyper- 
plasia, and  finally  "cheesy"  degeneration. 

Symptoms. — The  invasion  may  be  attended  by  nasal  or  laryn- 
geal catarrh,  or  both.  Usually  the  onset  begins  with  chilliness, 
followed  by  flushes  of  heat,  aching  pain  of  a  contused  character 
in  the  limbs,  joints,  and  trunk,  with  a  sense  of  fatigue  and  loss  of 
energy,  furred  tongue,  anorexia,  and  constipation.  In  nervous, 
irritable  individuals  and  in  children,  there  may  be  slight  delir- 
ium, and  in  very  young  children  during  the  period  of  dentition, 
convulsions  may  often  usher  in  an  attack. 

After  a  day  or  two  of  these  initial  symptoms,  those  charac- 
teristic of  bronchial  catarrh  develop. 

•  Pain  is  experienced  beneath  the  sternum,  especially  toward 
its  upper  part,  of  a  raw,  burning,  or  tearing  character,  aggra- 
vated by  a  deep  inspiration  or  by  coughing;  the  pain  also  radi- 
ates toward  the  sides,  following  the  course  of  the  primary  bron- 
chial tubes.  Tenderness  over  the  sternum  is  often  experienced. 
Muscular  pain  and  tenderness  of  rheumatic  character  are  often 
associated  with  attacks  of  bronchitis.  Cough  is  present  from 
the  onset,  at  first  in  paroxysms  of  a  hard,  dry  character,  chang- 


526 


ACUTE    BRONCHITIS. 


ing  as  the  disease  progresses,  and  becoming  looser,  followed  by 
free  expectoration.  The  expectoration,  at  first,  is  small  in 
quantity,  almost  transparent,  frothy,  often  streaked  with  blood, 
and  having  a  salty  taste.  As  the  disease  progresses  it  becomes 
more  abundant,  of  a  yellowish  or  a  greenish-yellow  color,  and 
of  a  tenacious  consistency.  There  are  present  slight  fever,  hot, 
dry  skin,  frequent  pulse,  loss  of  appetite,  moderate  thirst,  and 
constipation.  A  feeling  of  languor  and  weariness,  and  often 
considerable  depression,  quite  out  of  proportion  to  the  febrile 
state,  are  not  infrequent. 

Physical  Examination. — On  inspection,  palpation,  and  per- 
cussion there  are  no  evidences  of  any  abnormal  condition. 
Auscultation,  however,  reveals,  in  the  early  stage,  the  presence 
of  dry  rales,  sonorous  and  sibilant,  on  both  sides  of  the  chest,  and 
harsh  breath  sounds;  in  the  later  stage  when  expectoration  is 
profuse,  moist  bubbling  rales  are  heard. 

Diagnosis. — The  points  of  resemblance  and  difference  between 
acute  bronchitis  and  other  diseases  of  the  chest  will  be  pointed  out 
when  those  affections  are  described.  The  most  likely  conditions 
to  be  confused  with  acute  bronchitis  are  bronchopneumonia  and 
influenza ;  the  chief  points  of  difference  are  shown  in  the  follow- 
ing table  from  Gould  and  Pyle's  Cyclopedia: 


Acute  bronchitis. 


Influenza. 


Bronchopneumonia. 


Subjective  symptoms. 

May  occur  at  any  age .  . 

Pain  in  region  of  ster- 
num. 

Objective  sym-ptoms. 

Respirations  normal  or 
only  slightly  increased. 

Fever  slight  or  entirely 
absent;  pulse  in  pro- 
portion. 

In  early  stages  sonorous 
and  sibilant  rales;  later, 
mucous  rales  are  heard. 


Subjective  sym-ptom.s . 

May  occur  at  any  age .... 

Pain  in  forehead  or  back 
of  neck ;  general  bodyache 

Objective  symptoms . 

Respirations  slightly 
increased. 

Pulse  small,  rapid,  irreg- 
ular, moderate  and  often 
high  fever   (103°   to    104° 

Same  as  acute  bronchitis. 


Subjective  sym-ptom-s. 

Most   frequent    in    young 

or  very  old. 

Pain  in  region  of  chest. 


Objective  sym-ptoms. 

Respirations  exaggerated ; 
dyspnea  may  be  present; 
livid  color  of  lips. 
High    fever;    pulse    rapid 
and  feeble. 


3.   Subcrepitant     rales    over 
base  of  lungs  posteriorly. 


ACUTE    BRONCHITIS.  527 

The  association  of  bronchitis  with  other  diseases  must  not  be 
forgotten. 

Prognosis. — Acute  bronchitis  of  the  larger  tubes  usually  termi- 
nates in  complete  resolution  within  two  weeks.  In  children  and 
in  the  aged,  the  course  is  more  protracted,  and  the  symptoms 
more  severe,  but  recovery  is  the  rule.  Very  aged  and  feeble 
persons  may  rarely  succumb. 

Treatment. — The  patient  should  be  confined  to  a  warm  but 
well-ventilated  room,  and  if  aged  or  extremely  young  and  feeble, 
placed  in  bed.  Soft  diet  should  be  perscribed.  A  free  movement 
of  the  bowels  should  be  obtained  by  the  administration  of  frac- 
tional doses  of  calomel  followed  by  magnesia  or  some  other  saline. 
The  action  of  the  skin  should  be  rendered  free  by  the  employment 
of  the  hot  foot-bath,  hot  drinks,  and  Dover's  powder.  During 
the  stage  of  invasion,  quinin  sulphate,  gr.  x  (0.6  gm.),  combined 
with  morphin  sulphate,  gr.  1/6  (o.oii  gm.),  will  usually  prevent 
or  abort  an  attack.  In  the^^r^^  stage,  in  adults,  when  the  mucous 
membrane  is  swollen  and  dry,  the  sedative  expectorants  or  either 
of  the  following  perscriptions  will  give  prompt  relief: 

I^.      Antimonii  et  potassii  tart.  .    gr.  ij  .13  gm. 

Liquor,  ammonii  acetatis.  .    5iv  120.        c.c. 

Spts.  setheris  nitrosi 5  j  30 .        c.c. 

(Tinct.  aconiti,  if  indicated)   5j  4.        c.c. 

Syr.  simplicis ad     §vj       ad   180.        c.c. 

M.  S. — Two  teaspoonfuls  every  two  or  three  hours. 

Or— 

I^.      Vini  ipecacuanhae foj  4-  c.c. 

Liq.  potassii  citrat f^iij  90-  c.c. 

Liq.  ammonii  acetat....    fSiij  90  •  c.c. 

M.  S. — Tablespoonful  every  two  or  three  hours. 

If  the  cough  of  the  dry  stage  is  severe  or  if  diarrhea  follow 
the  use  of  either  of  the  above  combinations,  camphorated  tincture 
of  opium  (paregoric) or  codein  or  heroin,  may  be  added  with  ad- 
vantage, but  caution  should  always  be  exercised  in  the  use  of 
opium  in  the  dry  stage.  Tincture  of  hyoscyamus,  n^x  to  xv 
(0.3  to  I  CO.),  may  be  employed  instead. 


0 


28  ACUTE    BRONCHITIS. 


For^^oung  children,  the  above  combinations  in  proportionately 
reduced  doses  or  the  following  naa}^  be  used  with  benefit : 

I^.     Pulv.  ipecac,  et  opii gr.  v  3 .        gm. 

Pulv.  scillce gr.  x  .  6     gm. 

Hydrarg^Ti  chlor.  mitis  .  gr.  ij  .  13  gm. 

Sacch.  lact gr.  x  .  6     gm. 

M.     Ft.  chart.  No.  x. 

S. — One  every  two  hours. 

The  following  is  an  excellent  mixture  for  children : 

R.      Potassii  citrat oij  8 .  gm. 

S3^r.  ipecac f  oij  8  .  c.c. 

S5T.  scillae f  oj  4  .  c.c. 

Syr.  limonis f  oij  8  .  c.c. 

Tinct.  opii  camphorat  .  .   f  oij  8.  c.c. 

Elix.  simplicis  .  .  .q.  s.  ad  f  5iij  q.  s.  ad  90.  c.c. 
M.  S. — Teaspoonful  every  two  hours. 

Locally,  in  this  stage,  counterritation  is  often  of  great  value. 
Mustard  plasters,  or  turpentine  stupes,  or  even  a  few  dry  or  wet 
cups  over  the  sternum  will  in  many  cases  serve  to  relieve  the  sub- 
sternal pain  and  bronchial  congestion. 

Second  Stage. — The  secretion  of  the  bronchial  mucous  mem- 
brane  being  copious,   stimulating  expectorants   are    indicated,- 
such    as     ammonium     chlorid,    ammonium    carbonate,    squill, 
potassium  carbonate,  etc.     A  reliable  combination  is  : 

R.      Ammonii  chloridi oij  8.  gm. 

Scillae  aceti f  oiij  12  .  c.c. 

Syr.  ipecac f  oij  8  .  c.c. 

Mist,   glycyrrhizae  comp. 

q.  s.  ad  f  oiij        q.  s.  ad  90.  c.c. 
M.  S. — Dessertspoonful  every  three  hours. 

Attacks  showing  a  tendency  to  linger  are  greatly  benefited  by 
the  following: 

R.      Terebeni .  .  .• f  oij  8  .     c.c. 

Creosoti rr|xxiv  i .  5  c.c. 

Mucil.  acacias q.  s.         q.  s. 

Aquae  chloroformi.  .    q.  s.  f§iij        q.  s.  ad.  90  c.c. 
M.  S. — One  teaspoonful  every  four  hours,  diluted. 


CHRONIC    BRONCHITIS.  529 

In  debilitated  individuals,  alcohol  and  strychnin  are  necessary 
to  overcome  the  depression.  During  convalescence  these  and 
other  tonics  such  as  iron,  quinin  and  cod-liver  oil  are  indicated. 
A  change  of  climate  is  beneficial. 

CHRONIC  BRONCHITIS. 

Synonyms. — Chronic  bronchial  catarrh ;  winter  cough ;  second- 
ary bronchitis. 

Definition. — A  chronic  inflammation  of  the  mucous  mem- 
brane of  the  larger  and  middle-sized  bronchial  tubes;  charac- 
terized by  cough  and  more  or  less  profuse  expectoration,  plus, 
in  many  cases,  the  symptoms  of  emphysema  of  the  lungs. 
Chronic  bronchitis  may  be  either  primary  or  secondary. 

Causes. — It  may  follow  a  succession  of  acute  attacks,  or  it 
may  be  due  to  exposure  to  cold  and  wet  or  the  repeated  inhala- 
tion of  dust,  vapors,  or  other  irritants.  It  is  common  in  the 
aged.  The  affection  may  accompany  the  infectious  fevers,  as 
typhoid  fever,  influenza,  measles,  etc.,  and  pulmonary,  cardiac, 
or  renal  disease,  or  it  may  arise  indirectly  from  gout,  rheuma- 
tism, syphilis,  and  alcoholism. 

Varieties. — I.  Mucous  catarrh,  associated  with  moderate 
expectoration.  II.  Bronchorrhea,  profuse  expectoration.  III. 
Dry  catarrh,  scanty  expectoration.  IV.  Fetid  bronchitis.  V. 
Bronchiectasis,  or  dilatation  of  the  bronchi. 

Pathologic  Anatomy. — The  mucous  membrane  of  the  bron- 
chial tube  is  discolored,  being  of  a  more  or  less  dull  red,  often 
of  a  deeply  venous  blue,  mingled  with  a  grayish  or  brownish 
color.  These  changes  may  be  either  in  patches  or  extensively 
diffused.  The  vessels  of  the  mucous  membrane  are  dilated. 
The  mucous  membrane  is  thickened,  resulting  in  reduction  in 
the  caliber  of  the  tube  and  a  roughening  of  its  internal  surface. 
The  submucous  tissue  becomes  infiltrated,  contracted,  and 
indurated.  The  elastic  and  muscular  coats  of  the  tubes  become 
hypertrophied,  lose  their  elasticity,  and  the  cartilages  become 
the  seat  of  calcareous  deposits. 

As  the  result  of  the  loss  of  elasticity  and  muscular  tone  of  the 
34 


530  CHRONIC    BRONCHITIS. 

tubes  they  become  irregularly  dilated — "bronchial  dilatation." 
The  dilatations  may  be  uniform  in  character,  resembling  some- 
what the  fingers  of  a  glove,  or  they  may  be  sacculated  or  globu- 
lar, forming  actual  cavities  in  the  bronchial  structure. 

In  the  mucous  variety  the  secretion  consists  of  young  cells 
and  mucous  corpuscles,  having  a  yellowish  color;  in  the  dry 
variety,  the  "  catarrhe  sec"  of  Laennec,  or  "dry  bronchial 
irritation,"  the  secretion  is  scanty,  tough,  semi-transparent, 
and  occurs  in  globular  masses;  in  bronchorrhea,  which  is  usually 
associated  with  bronchial  dilatation,  the  secretion  is  abundant, 
greenish  yellow  in  color,  and  frequently  fetid. 

The  majority  of  cases  of  chronic  bronchitis  are  associated  with 
chronic  gastric  catarrh. 

Symptoms. — The  most  characteristic  symptoms  of  chronic 
bronchitis  are  the  cough  and  expectoration.  The  cough  may 
occur  at  all  hours,  but  is  more  severe  at  night  and  early  in  the 
morning.  The  cough  is  not  always  present.  It  disappears 
almost  altogether  for  a  time,  and  then  reappears,  continuing 
thus  for  years.  Coated  tongue,  disagreeable  taste,  loss  of 
appetite,  impaired  digestion,  with  eructations  of  gases,  are 
present  in  many  cases,  due  to  the  chronic  gastric  catarrh. 
Unless  associated  with  other  diseases,  the  general  health  suffers 
but  little,  if  at  all;  constitutional  symptoms  being  present  only 
during  acute  exacerbations. 

Mucous  catarrh,  or,  from  its  occurring  most  commonly  during 
the  winter  months,  "winter  cough,"  is  characterized  by  parox- 
ysms of  cough,  more  or  less  violent,  followed  by  the  expectora- 
tion of  a  yellowish  mucus. 

Dry  catarrh  is  characterized  by  a  harsh  cough,  a  feeling  of  sore- 
ness or  rawness  under  the  sternum,  and  the  expectoration  of 
small  globular  masses;  this  variety  occurs  with  emphysema, 
gout,  rheumatism,  and  asthma. 

Bronchorrhea,  which  is  associated  with  bronchial  dilatation, 
and  most  common  in  the  elderly,  is  characterized  by  paroxysms 
of  severe  coughing,  followed  by  the  copious  expectoration  of 
greenish  yellow,  often  fetid,  mucus;  the  quantity  expectorated 
often  amounts  to  four  or  five  pints  in  the  twenty-four  hours. 


CHRONIC    BRONCHITIS.  531 

Fetid  bronchitis ,  often  associated  with  bronchial  dilatation,  has 
an  excessively  fetid  odor  of  the  breath  and  expectoration.  The 
decomposition  of  the  secretion  may  cause  gangrene  of  the  bron- 
chial mucous  membrane,  and  even  of  the  lung-structure. 

Physical  Signs. — Percussion  yields  a  normal  note  in  simple, 
uncomplicated  cases.  In  the  presence  of  bronchial  dilatation 
there  are  diffused  spots  of  the  tympanitic  or  amphoric  percussion - 
sound,  the  physical  condition  being  a  circumscribed  cavity 
containing  air  and  communicating  with  a  bronchial  tube. 

Auscultation  reveals  the  presence  of  harsh  or  vesiculo-bron- 
chial  respiration  associated  with  more  or  less  profuse,  sonorous, 
sibilant,  and  large  and  small  bubbling  rales;  in  bronchial  dilata- 
tion, in  addition  to  the  harsh  respiration,  is  found  broncho- 
cavernous  breathing,  with  large  and  small  gurgling  rales. 
Should  emphysema  complicate  chronic  bronchitis,  the  physical 
signs  are  somewhat  modified,  and  will  be  pointed  out  when 
discussing  that  affection. 

Diagnosis. — Always  examine  the  urine  in  case  of  cough,  and 
particularly  in  chronic  bronchitis,  as  this  condition  is  one  of  the 
most  frequent  complications  of   Bright's  disease. 

Incipient  phthisis  is  often  confounded  with  chronic  bronchitis. 
The  diagnosis  is  not  always  easy.  The  physical  signs  of  chronic 
bronchitis  are  more  or  less  diffused  through  both  lungs,  and  not, 
as  a  rule,  associated  with  failure  of  the  general  health;  while  in 
phthisis,  from  the  onset,  there  is  failing  health,  with  a  concentra- 
tion of  the  physical  signs  to  the  apices.  The  discovery  of  the 
bacillus  determines  the  diagnosis. 

Bronchiectasis  may  be  distinguished  from  chronic  bronchitis 
by  the  paroxysmal  coughing,  copious  expectoration,  and  physical 
signs  indicating  one  or  more  cavities  near  the  base  of  the  lung. 

Emphysema  is  characterized  by  uniform  distention  of  the 
chest,  dyspnea,  hyper-resonance,  and  feeble  expiration. 

Asthma  is  attended  by  marked  dyspnea,  hyper-resonance  on 
percussion,  dry  and  moist  rales  on  auscultation,  and  expectora- 
tion of  Curschmann's  spirals  and  Charcot-Leyden  crystals. 

Prognosis. — If  unassociated  with  disease  of  the  lungs,  heart, 
or  kidneys,  chronic  bronchitis  is  never  dangerous  to  life,  although 


532  CHRONIC    BRONCHITIS. 

the~ symptoms  are  present,  more  or  less,  continually,  and  aggra- 
vated upon,  the  least  exposure.  Rarely  is  a  complete  cure 
recorded. 

If  associated  with  phthisis,  emphysema,  diseases  of  the  heart 
or  of  the  kidneys,  the  prognosis  is  governed  by  these  affections. 
In  turn,  it  is  to  be  remembered  that  chronic  bronchial  catarrh 
may  lead  to  emphysema  of  the  lungs,  bronchiectasis,  asthma,  or 
to  cardiac  dilatation. 

'Treatment. — In  all  cases,  a  careful  examination  should  be 
made  of  all  the  organs  to  determine  whether  the  affection  is 
primary  or  secondary.  When  dependent  upon  some  other 
disease  the  greater  portion  of  the  treatment  should  be  directed 
toward  the  underlying  condition.  Warmth  is  beneficial  in  all 
cases.  The  patient  should  be  protected  from  cold  by  wearing 
woolen  or  silk  underclothing  the  year  round,  being  careful, 
however,  not  to  clothe  to  excess.  Draughts,  wet  feet,  etc., 
should  be  guarded  against.  A  warm  atmosphere  is  especially 
beneficial,  and  when  possible  the  patient  should  be  removed 
to  a  warm  climate.  If  the  expectoration  is  profuse,  a  warm 
dry  climate  is  indicated,  but  if  the  expectoration  is  very  scant, 
the  opposite,  a  moist,  warm  climate  is  recommended. 

The  medicinal  treatment  has  for  its  object  the  restoration  of 
the  normal  tone  of  the  body  and  the  lessening  of  the  local  infla-m- 
mation.  The  first  indication  is  met  with  by  the  administration 
of  iron,  quinin,  strychnin,  arsenic,  cod-liver  oil,  etc.  In  the  pres- 
ence of  organic  disease  special  medicinal  treatment  is  required  in 
addition.  In  cases  dependent  upon  the  uric  acid  diathesis  the 
iodids  and  alkalies  should  be  administered  over  an  extended 
period,  and  the  patient  should  be  advised  to  seek  a  residence  at 
one  of  the  alkaline  springs.  When  the  condition  is  associated 
with  alcoholism  or  chronic  gastric  catarrh,  the  following  com- 
bination is  of  value : 

I^.      Ammonii  chloridi   5iij  12 .  gm. 

Tinct.  nucis  vomica.  .  .   .    f  5ij  8.  c.c. 

Inf  s.  gentiance  comp., 

q.  s.  ad  f  §iv       q.  s.  ad  120.  c.c. 
M.  S. — Dessertspoonful  in  water  before  meals. 


CHRONIC    BRONCHITIS.  533 

The  bronchial  inflammation  itself  calls  for  the  use  of  stimu- 
lating expectorants,  prominent  among  which  may  be  mentioned 
ammonium  chlorid,  ammonium  carbonate,  benzoic  acid,  bal- 
sams of  Peru  and  Tolu,  tar,  squill,  turpentine,  oil  of  eucalyptus, 
terebene,  santal  wood  oil,  cubebs,  copaiba,  creasote,  and  terpene 
hydrate. 

For  mucous  catarrh  with  acute  exacerbations: 


I^.      Ammonii  chloridi 3ij  8 

Glycerini f  Biss  45 

Codeinae  sulph gr.j 

Vini  picis  liq f  §iij  9° 

Syr.  prun.  virg. f  oiss  45 


gm. 

CO. 

065  gm. 
c.c. 

CO. 


M.  S.— Tablespoonful  every  three  or  four  hours. 
Dry  catarrh  is  greatly  benefited  by: 

'Bf.      Potassii  iodidi gr.  v  to  x      .  3  to  .  6  gm. 

Elix.  cinchonae ttI^x  i  .3  c.c. 

Vini  picis  Hq adfossad     15.  c.c. 

M.  S. — Three  times  a  day. 

For    an    acute    exacerbation    of    dry    or    tenacious    chronic 
bronchitis : 

^.     Ammonii  chloridi oiv  15  .  gm. 

Tinct.  hyoscyam f  5iv  15.  c.c. 

Syr.  scillae  comp f  oiv  15.  c.c. 

Aq.  chloroformi f  5ij  60.  c.c. 

M.  S. — One  teaspoonful  every  three  hours,  diluted. 

An  excellent  expectorant  combination  in  all  forms  and  at  any 

stage  of  bronchial  catarrh  is: 

J^.     Ammonii  carbonat gf-xvj  i  .  gm. 

'     Fluidextracti  scillae f5ss  2.  c.c. 

Fiuidextracti  senega.  .  .  .  f  oss  2  .  c.c. 

Tinct.  opii  camphorat.  .  .  f  5iij  12.  c.c. 

Syr.  Tolu f  oiss  45  •  c.c. 

M.  S. — Teaspoonful  every  few  hours,  diluted. 


534  CHRONIC    BRONCHITIS. 

Or— 

I^.     Fluidextracti  eucalypti .  .       §i  30.  gm. 

Ammonii  chlorid oi  4.  gm. 

Ext.  glycyrrhizae oii  8.  gm. 

Syrup.  Tolutani f  Siii  90.  c.c. 

M.  S. — One  teaspoonful  every  three  hours.  (Potter.) 

Or— 

I^.      Ammonii  chlorid gr.  xxx  2  .  gm. 

Tr.  opii  camph. 

Syr.  ipecac ad  f  5iii  ad     11.  c.c. 

Syr.  pruni  Virg f  5i  30.  c.c. 

Syr.  Tolutani. ..  .q.  s.  ad  f5iv       q.s.adi20.  c.c. 
M.  S. — Teaspoonful  every  three  hours. 


Or- 


I^.      Acid  hydrocyanici  dil .  .  .    ttj^xx  1.23  c.c. 

Ammonii  carb gr.  xl  2.6  gm. 

Syr.  Tolutani f  5iv  120.  c.c. 

Aquae q.  s.  ad  f  gviii  q.  s.  ad  240.  c.c. 

M.  S. — Four  teaspoonfuls  every  three  hours. 


Or- 


J\.     Syr.  scillas fSss  15.  c.c.     . 

Tr.  opii  camph f  5ii  8  .  c.c. 

Ammoniac 5ss  2  .  gm. 

Syrup  Tolutani f  ox  38  .  gm. 

M.  S. — Teaspoonful  as  the  occasion  requires.      (Potter.) 

In  the  bronchorrheal  type  of  the  disease,  copaiba, rr^v  to  x 
(0.3  c.c.  to  0.6  c.c),  every  three  hours,  spirit  of  turpentine, 
nxv  (0.3  c.c),  every  four  hours,  carbolic  acid,  gr.  ss  (0.032  gm.), 
four  times  daily,  or  the  following  combination  should  be 
administered : 

I^.      Terebeni f  5ij  8 .  c.c. 

Creosoti nxxxx  2  .  c.c. 

Acacias q.  s.  q.    s. 

Aq.  chloroformi f  5j  30.  c.c. 

Syr.  prun.  virg.  .  .q.s.  ad  f  5iij         q.  s.  ad  90.  c.c. 
M.  S. — Teaspoonful  every  three  or  four  hours,  diluted. 


FIBRINOUS    BRONCHITIS.  535 

Or— 

I^.      Copaibae, 

Syr.  Tolutani aa      5iv  1 5  .   c.c. 

Spt.  etheris  nitrosi f§i  30.  c.c. 

Aquae  menth.  pip f  5ii  60 .  c.c. 

M.  S. — Teaspoonful  every  four  hours  (Potter). 

In  fetid  bronchitis,  Da  Costa  recommends  the  internal  admin- 
isteration  of  carbolic  acid,  nxi  (0.06  c.c.)  every  third  hour  with 
inhalations  of  the  vapor  of  water  containing  carbolic  acid,  gr.  v 
(0.32  gm.),  to  the  fiuidounce  (30  c.c), two  or  three  times  daily. 
The  following  inhalation  may  also  be  used : 

I}.      Creasote  (beechwood)  .  .  .    f5i  4.  c.c. 

Eucalyptol f  5i  4  .  c.c. 

Tr.  benzoin  comp fBii  60.  c.c. 

M.  S.— Add  one  teaspoonful  to  a  pint  of  boiling  water  and 
use  as  an  inhalation  twice  daily. 

Locally,  counterirritation  in  the  form  of  flying  blisters,  or  tinc- 
ture of  iodin  repeated  once  or  twice  a  week  is  of  advantage. 

FIBRINOUS  BRONCHITIS. 

Synonyms. — Plastic   bronchitis;   membranous   bronchitis. 

Definition. — An  acute  inflammation  of  the  mucous  membrane 
of  the  larger  and  middle-sized  bronchial  tubes,  attended  with 
an  exudation,  forming  a  membranous  layer,  which  is  closely 
adherent  to  the  mucous  surface;  characterized  by  febrile  reac- 
tion, cough,  difficult  breathing,  and  scanty  expectoration, 
followed  by  the  expulsion  of  the  false  membrane  in  the  form 
of  patches  or  casts. 

Causes. — The  direct  cause  is  unknown.  The  affection  is 
frequently  associated  with  tuberciilosis ;  less  often  with  other 
conditions  such  as  membranous  laryngitis,  asthma,  emphysema, 
typhoid  fever,  pneumonia,  certain  skin  diseases,  or  disturb- 
ances of  menstruation.  It  may  occur  in  those  of  feeble  health, 
or  in  tuberculous  constitutions,  so-called,  or  it  may  result  from 


536  FIBRINOUS    BRONCHITIS. 

exposure  to  cold  and  damp.  Spring  season,  adult  life,  and 
male  sex  are  predisposing  factors. 

Pathologic  Anatomy. — The  affection  begins  with  hyperemia 
of  the  mucous  membrane  of  the  bronchial  tubes,  associated  with 
swelling  and  edema.  Later  the  surface  is  covered  with  a 
whitish  or  grayish -white,  firmly  adherent,  membranous  deposit, 
cemented  together  by  a  coagulable  exudation  and  prolonged 
from  its  under  surface  into  the  bronchial  follicles.  Sooner  or 
later  it  is  loosened  and  detached  by  a  suppurative  process  and 
is  expectorated  after  a  violent  paroxysm  of  coughing  or  vomit- 
ing. When  expectorated,  the  false  membrane,  as  it  has  been 
termed,  has  either  the  form  of  patches,  or  is  thrown  off  entire 
from  the  bronchial  tube,  and  may  be  found  to  consist  of  casts 
representing  more  or  less  of  the  bronchial  subdivisions,  and 
presenting  an  appearance  not  unlike  "boiled  macaroni." 

On  microscopic  examination,  the  detached  membrane  pre- 
sents fibrill^  which  characterize  fibrin  or  lymph  in  other  situa- 
tions; and  if  placed  in  a  solution  of  acetic  acid,  it  becomes  greatly 
swollen,  while  ordinary  mucus  contracts  and  becomes  more 
dense  if  added  to  the  same  solution.  Charcot-Leyden  crystals, 
Curschmann's  spirals,  leukocytes,  fat-droplets,  and  epithelium 
may  be  found  in  the  casts. 

Symptoms. — There  are  no  symptoms  or  signs  by  means  of 
which  this  variety  of  bronchitis  can  be  distinguished  from 
ordinary  catarrhal  bronchitis,  prior  to  the  expectoration  of  the 
false  membrane. 

Expectoration  is  preceded  and  accompanied  by  violent 
paroxysms  of  coughing,  and  after  more  or  less  of  the  membrane 
has  been  raised,  a  muco-purulent  expectoration,  streaked  with 
blood,  may  be  present  for  several  days. 

Duration. — The  inflammation  may  be  either  actite,  subacute,  or 
chronic,  expectoration  of  patches  or  strips  of  the  membrane 
being  repeated  at  intervals  of  days,  weeks,  months,  or  even 
years. 

Prognosis. — In  adults,  the  outlook  is  favorable,  if  not  asso- 
ciated with  other  grave  affections,  such  as  phthisis,  pneumonia, 
emphysema.      In  young  children   it  may  cause  obstruction  to 


HAY   FEVER.  537 

the  respiration,  and  not  infrequently  proves  fatal.  The  acute 
form  is  most  vSerious. 

Treatment. — As  the  character  of  the  inflammation  can  seldom 
be  determined  until  the  membrane  or  portions  of  it  have  been 
expectorated,  the  treatment  is  at  first  the  same  as  in  attacks  of 
ordinary  acute  bronchitis. 

As  soon,  however,  as  the  character  of  the  inflammation  can  be 
determined,  active  emesis  is  the  most  effective  means  of  re- 
moving the  obstruction  caused  by  the  false  membrane,  the  best 
agents  of  this  class  being  yellow  mercuric  subsulphate  (turpeth 
mineral),  apomorphin,  ipecac,  and  zinc  sulphate.  Inhalations 
of  the  vapor  of  alkaline  solutions  such  as  lime-water  and  solu- 
tion of  sodium  bicarbonate,  gr.  xxx  to  the  fluidounce  (2  gm.  to 
30  c.c),  ammonium  chlorid,  tar  (pix  liquida),  and  eucalyptol 
may  also  be  employed  in  inhalations.  To  prevent  the  forma- 
tion of  the  membrane,  Bartholow  urges  the  use  of  ammonium 
iodid  and  ammonium  carbonate  combined,  in  small  doses  every 
two  hours.  Potassium  iodid  is  also  of  value.  Counterirritation 
to  the  chest  is  of  benefit  in  cases  which  tend  to  become  chronic. 
Arsenic  and  pix  liquida  should  also  be  given  in  these  cases. 

HAY  FEVER. 

Synonyms. — Hay  asthma;  autumnal  catarrh;  rose  cold. 

Definition. — An  acute,  catarrhal  inflammation  of  the  upper 
air-passages,  extending  to  the  bronchial  tubes,  associated  with 
spasmodic  contraction  of  their  muscular  layer,  occurring  at  a 
particular  season  of  the  year,  characterized  by  coryza,  croupy 
or  wheezy  cough,  and  difficult  respiration. 

Causes. — The  nervous  system  especially  seems  to  predispose  in 
many  cases.  Heredity,  sedentary  life,  uric  acid  diathesis,  nasal 
disease,  and  neurotic  constitution  are  important  etiologic  fac- 
tors. The  disease  becomes  manifest  in  the  spring  and  autumn, 
and  the  attacks  may  be  brought  about  by  the  inhalation  of 
irritating  dusts  or  vapors,  or  the  pollen  of  grasses,  rye,  com, 
wheat,  or  roses.  The  affection  is  encountered  most  frequently 
in  the  cities  and  in  low  countries. 


538  HAY   FEVER. 

Pathology. — A  hyper-sensitiveness  of  the  nasal  mucous  mem- 
brane is  believed  to  be  the  only  change.  Associated  with  this, 
however,  it  is  rather  common  to  find  hypertrophic  rhinitis, 
enlargement  of  the  inferior  and  middle  turbinated  bones,  nasal 
polyps,  and  deflection  of  the  nasal  septum,  the  relief,  of  which 
conditions  is  often  followed  by  cure  of  the  hay  fever. 

Symptoms. — The  affection  begins  with  remarkable  regularity 
about  the  same  time  each  year.  The  attack  begins  with  irrita- 
tion of  the  eyes,  coryza,  and  sneezing,  with  a  clear  watery  nasal 
discharge.  The  congestion  extends  to  the  Eustachian  tube  and 
to  the  larynx  and  bronchial  tubes,  thereby  inducing  a  hoarse, 
croupy,  and  wheezing  cough,  with  difficulty  in  breathing.  The 
dyspnea  occurs  in  paroxysms,  which  are  often  as  severe  as  those 
occurring  in  true  asthmatic  attacks.  Mild  nervous  depression  is 
usually  present.  The  paroxysms  remit  after  a  few  days,  to  recur 
after  an  interval  of  several  days  or  weeks,  and  to  be  followed 
by  another  remission,  and  so  on  until  the  season  changes.  The 
bronchial  catarrh  persists  during  the  entire  attack.  Constitu- 
tional symptoms  are  mild  in  the  absence  of  complications. 

Complications. — Capillary  bronchitis,  congestion  or  edema  of 
the  lungs,  or  pneumonia  may  occur  as  complications. 

Duration. — Unless  a  change  of  climate  is  resorted  to,  parox- 
ysms of  hay  fever  continue  more  or  less  severe  for  six,  eight,  or 
ten  weeks  of  the  year,  each  year  the  paroxysms  growing  more 
severe. 

Prognosis. — The  affection  never  proves  fatal  in  itself,  but  one 
or  more  of  the  following  sequelae  may  result,  asthma,  chronic 
bronchitis,  or  loss  of  the  special  senses  of  hearing  or  of  smelling. 

Treatment. — .There  is  no  specific.  In  those  cases  in  which 
nasal  disease  exists,  considerable  relief  may  be  afforded  by  at- 
tention to  the  nasal  channels. 

An  attack  of  hay  fever  is  often  prevented  by  a  change  of 
climate  during  the  season  of  the  year  when  the  attacks  are  most 
common  (the  early  autumn) .  Any  of  the  following  locations  may 
be  selected:  White  Mountains,  Catskills,  Adirondacks,  Rocky 
Mountains,  or  a  sea  voyage.  Certain  seaside  resorts,  par- 
ticularly Long  Branch,  Beach  Haven,  Fire  Island,  Nantucket,  and 


HAY   FEVER.  539 

Mount  Desert,   seems  to  be  especially  beneficial  to  hay  fever 
patients. 

The  condition  of  the  general  health  should  receive  very  close 
attention.  Many  patients  are  more  or  less  run  down  and  re- 
quire tonics,  such  as  iron,  strychnin,  arsenic,  quinin,  phosphorus, 
etc.,  over  an  extended  period. 

I^.      Liq.  potass,  arsenit oi  4-  c.c. 

Syr.  hyphosphos  .  q.  s.  ad    5iv  120.  c.c. 

M.  S. — Two  teaspoonfuls  after  meals. 

Or— 

I^.      Ext.  belladonnae 

Ext.  cannabis  Indicae  .aa  gr.  i  aa      .065  gm. 

Camphor gr.  xv  i .  gm. 

Quinin.  sulphatis gr-  xx  i  .  296  gm. 

M.     Disp.  in  capsul.  No.  vi. 
S. — One  every  three  hours. 

The  digestive  tract  should  be  carefully  examined.  Indigestion 
should  receive  prompt  treatment.  Constipation  should  be 
avoided.  Fruit  and  vegetables  should  form  the  greater  portion 
of  the  diet,  and  animal  foods,  coffee,  and  tea,  should  be  inter- 
dicted. All  the  avenues  of  excretion  should  be  maintained  in 
their  normal  coundition.  Frequent  hot  baths,  massage,  electric- 
ity, diuretics,  and  diaphoretics  may  be  employed  with  this  end 
in  view. 

The  attacks  may  apparently  be  aborted  at  times,  by  internal 
treatment.  Quinin  sulphate,  gr.  v  (0.3  gm.), three  times  daily, 
administered  one  month  before  the  attack  is  expected,  has  been 
successful.  Dover's  powder,  gr.  v  (o.3gm.),  three  times  daily, 
or  the  following  may  be  used  for  the  same  purpose : 

I^.     Atropinae  sulph gr.  1/5  .012  gm. 

Morphinae  sulph gr.  1/4  .016  gm. 

Strychninae  sulph gr.  1/8  .008  gm. 

Quininae  hydrochlorid .  .  .  gr.  x  .65     gm. 

Sodii    arsenat gr.  1/6  .011  gm. 

M.    Ft.  pil.  No.  XXX. 

S. — One  every  hour  until  dryness,  then  two  or  three  hours 
apart. 


540  ASTHMA. 

The  following  is  of  benefit  during  the  attack : 

I^.      Ext.  hyoscyami gr.  xii  .  775  gm. 

Potass,  iodid 5i  4.  gm. 

Potass,  bicarb 5ii  8..  gm. 

•                Ext.  glycyrrhizas 5iv  15 .  gm. 

Aquae  anisi f  §ivss  136  .  c.c. 

M.    S. — Dessertspoonful    every    four  hours  until    relieved 
(Weber) . 

The  application  of  tablets  of  cocain  hydrochlorid,  gr.  1/6 
(0.0 1 1  gm.),  or  the  same  drug  in  4  per  cent,  solution  every  two 
or  three  hours  will  afford  great  relief.  The  possibility  of  con- 
tracting the  cocain  habit  from  this  treatment  should  not  be  over- 
looked. A  much  safer  plan  is  to  apply  pledgets  of  cotton  soaked 
in  a  solution  of  adrenalin  hydrochlorid  (i  to  4000).  Bartholow 
advises  the  thorough  application  of  quinin  to  the  nares.  The 
following  application  is  also  of  value : 

I^.      Mentholis 5  j  4 .  gm. 

Phenolis 5ss  2  .  gm. 

Zinci  oxidi 5  j  4  .  gm. 

01.  amygd.  dulcis §jss  45.  c.c. 

Cerati  simplicis.  . Sij  60.  gm. 

M.  S. — Apply  thoroughly  to  the  nostrils  every  few  hours. 


ASTHMA. 

Synonyms. — Bronchial  asthma;  spasmodic  asthma. 

Definition. — A  paroxysmal,  spasmodic  contraction  of  the  mus- 
cular layer  surrounding  the  smaller  bronchial  tubes,  and  perhaps 
associated  with  a  tonic  spasm  of  the  diaphragm  and  more  or  less 
bronchial  catarrh;  characterized  by  spasmodic  attacks  of  dis- 
tressing expiratory  dyspnea,  continuing  several  hours,  days,  or 
weeks 

Causes. — The  affection  is  believed  to  be  a  true  neurosis  of  the 
respiratory  apparatus.  It  may  result  from  peripheral  or  local 
disturbances  in  the  nervous  system.      In  many  cases  there  is  a 


ASTHMA.  541 

family  history  of  asthma,  chorea,  or  epilepsy.  It  is  more  com- 
mon in  men  than  in  women,  and  may  occur  at  any  age.  At- 
mospheric and  climatic  changes  may  act  as  causes.  Some  cases 
are  of  reflex  origin. 

Frequently  the  affection  is  due  to  disease  of  the  nasal  or 
bronchial  mucous  membrane,  bronchitis,  emphysema,  chronic 
cardiac  disease,  chronic  gastric  catarrh,  and  malarial  toxemia. 
The  inhalation  of  irritating  substances  such  as  ipecac,  turpentine, 
dust,  etc.,  may  precipitate  an  attack. 

Pathology. — Except  in  the  presence  of  bronchitis  or  other 
atlection  there  are  no  structural  changes.  The  attacks  consist 
in  spasm  of  the  muscular  coat  with  vasomotor  turgescence  of 
the  mucous  coat  of  the  bronchi. 

Symptoms. — The  onset  of  the  first  attack  of  asthma  is  abrupt, 
the  succeeding  attacks  being  preceded  by  prodromes,  which  the 
individual  rapidly  learns  to  appreciate — viz.,  coryza,  bronchial 
irritation,  thoracic  constriction,  marked  dyspepsia,  or  the  scanty 
passage  of  pale,  limpid  urine  (the  "hysterical  urine"). 

The  paroxysm  begins,  in  the  majority  of  instances,  in  the  early 
morning  hours  or  during  the  afternoon,  with  a  feeling  of  anguish 
and  constriction  in  the  chest  and  an  intense  desire  for  air.  The 
breathing  is  accompanied  with  loud  wheezing,  the  face  is  flushed,  at 
times  even  cyanosed  and  bathed  in  perspiration,  the  eyes  star- 
ing, the  eyeballs  protrude,  and  the  muscles  of  the  neck  become 
prominent  as  they  aid  in  the  effort  for  air.  The  dyspnea  soon 
becomes  so  severe  that  the  inspiration  is  but  a  gasp,  the  lips  are 
pallid,  cyanosis  deepens,  and  the  patient  feels  as  if  death  were 
impending.  Owing  to  the  tonic  contraction  of  the  smaller  bronchi 
the  air  drawn  into  the  alveoli  escapes  imperfectly,  resulting  in 
the  expiratory  dyspnea,  the  emphysematous  chest,  and  the 
lowered  position  of  the  diaphragm.  During  the  paroxysm  there 
is  a  short,  dry  cough,  becoming  more  loose  as  the  attack  subsides. 

After  some  minutes  or  hours  the  respiration  becomes  easier, 
the  air  in  the  lungs  changes,  the  cyanosis  disappears,  and 
gradually  the  paroxysm  ceases,  the  patient  feeling  exhausted 
and  the  chest  fatigued. 

The  sputum  of  asthma  is  unique.      Early  in  the  paroxysm  it  is 


542  ASTHMA. 

raised  with  difficulty,  and  takes  the  form  of  rounded  gelatinous 
masses  ("perles"  of  Laennec).  If  these  pellets  are  carefully  ex- 
amined, they  will  be  found  to  consist  of  molds  of  the  smaller 
bronchi,  and,  under  the  microscope,  show  Leyden's  crystals  and 
Curschmann's  spirals.  After  a  day  or  two  the  sputum  becomes 
muco -purulent,  and  the  spirals  and  crystals  are  absent. 

The  duration  of  an  attack  varies  from  one  to  many  hours,  or 
even  days.  Instead  of  single  paroxysms,  slight  remissions  may 
occur  at  intervals  of  one,  two,  or  three  hours,  to  be  followed  by 
exacerbations  lasting  from  four  to  six  hours,  continuing  for  a 
week  or  two,  preventing  the  patient  lying  down  or  taking  food. 

Physical  Signs. — Inspection  shows  marked  dyspnea,  with  dis- 
tention of  the  chest. 

Percussion  yields,  during  the  paroxysm,  hyper-resonance  or  a 
vesiculo-tympanic  note  (the  band-box  tone  of  Bamberger) 
over  both  lungs,  due  to  the  retained  air  in  the  alveoli. 

Auscultation  during  the  first  stage  reveals  a  feeble  or  absent 
vesicular  murmur,  with  prolonged  expiration,  associated  with 
loud,  wheezing,  whistling,  sibilant,  and  sonorous  rales;  as  the 
paroxysm  subsides,  the  vesicular  breathing  becomes  more 
noticeable,  and  is  accompanied  by  moist  rales. 

Prognosis. — The  disease  is  essentially  chronic  and  recovery 
seldom  occurs,  except  when  due  to  reflex  causes  that  may  be  re- 
moved. The  paroxysms  may  be  relieved  by  treatment.  In 
itself  asthma  is  not  fatal  to  life;  but  if  the  paroxysms  are  fre- 
quently repeated,  there  results  either  emphysema,  cardiac 
dilatation  with  subsequent  dropsy,  or  even  cerebral  hemorrhage. 

Attacks  of  asthma  frequently  occur  as  a  complication  in 
emphysema,  chronic  bronchitis,  valvular  diseases  of  the  heart, 
and  Bright's  disease. 

Treatment. — There  are  two  indications  to  meet — the  relief  of 
the  paroxysm,  and  prevention  of  its  recurrence. 

To  relieve  the  paroxysm,  no  medication  is  so  effective  as  the 
hypodermic  injection  of  morphin  sulphate,  gr.  i/6  to  1/4  (o.oii 
to  0.016  gm.),  combined  with  atropin  sulphate,  gr.  i/ioo 
(0.00065  gm.).  Chloral,  gr.  x  (0.6  gm.),  in  the  absence  of 
cardiac  complications  is  very  beneficial.      Inhalation  of  chloro- 


ASTHMA.  543 

form  or  a  few  drops  of  amyl  nitrite  will  also  serve  to  relieve 
the  paroxysm.  Drinking  of  strong  hot  black  coffee  or  the 
administration  of  citrated  caffein  gr.  iii  to  v  (0.2  to  0.3  gm.), 
hypodermically,  in  a  cachet,  or  in  solution,  is  of  great  value. 

The  following  combination  by  hypodermic  injection  is  often 
most  successful  in  relieving  an  attack  of  asthma,  and  particu- 
larly if  complicated  with  cardiac  or  nephritic  disease,  continuing 
the  combination  after  relief,  in  pill  form  or  solution,  at  ordinary 
intervals  for  several  days: 

I^.      Spirit,  glonoini rrLij  .  12       c.c. 

Strychninse  sulph gr.  1/50  .0013  gm. 

Morphinae  sulph gr.  1/20  .003     gm. 

M.  S. — One  dose.     For  hypodermic  use. 

Page  strongly  recommends  sodium  nitrate,  as  in  the  following 
formula : 

I^.      Pulv.  sodii  nitratis gr.  xxiv  i .  6  gm. 

Aquae f  5  j  30  .     c.c. 

M.   S. — Teaspoonful  at  once;  repeat  in  half  an  hour,  once 
or  twice  if  necessary. 

Dr.  Pepper  speaks  highly  of  the  following  for  the  paroxysm: 

I^.     Ammonii  bromidi oijss  10.  gm. 

Ammonii  chloridi oiss  6.  gm. 

Tinct.  lobeliae f  oiij  12  .  c.c. 

Spt.  aetheris  comp foj  30.  c.c. 

Syr.  acacia q.  s.   f  §iv  ad  120.  c.c. 

M.  S. — Dessertspoonful  in  water  every  hour  or  two,  diluted. 

The  nauseating  expectorants,  such  as  lobelia,  ipecac,  and 
squill,  are  at  times  of  value.  Fluidextract  of  grindelia,  rr^^xx 
(1.3  c.c),  repeated  every  two  hours,  is  sometimes  useful.  In- 
halations of  the  fumes  of  belladonna,  stramonium,  nitre  paper, 
or  ethyl  bromid,  or  the  use  of  the  various,  pastilles  or  cigarettes, 
are  of  great  benefit  in  many  cases.  A  20  per  cent,  solution  of 
menthol  and  oxygen  have  also  been  employed  in  the  same 
manner  with  success. 


544  ASTHMA. 

Among  the  best  drugs  at  our  disposal  are  potassium  iodid, 
gr.  V  to  X  (0.3  to  0.6  gm..),  every  three  hours  either  alone  or 
combined  with  tincture  of  belladonna,  nxv  (0.3  c.c),  or  nitro- 
glycerin, gr.  1/200  to  i/ioo  (0.00032  to  0.00065  g™--)-  An- 
other valuable  remedy  is  the  syrup  of  hydriodic  acid,  5ss  to  5j 
(  2  to  4  c.c.)  every  three  hours,  diluted.  If  an  attack  is  im- 
pending, it  may  often  be  aborted  by  drinking  freely  of  strong, 
black  coffee,  or  by  full  doses  of  the  bromids. 

Bartholow  employs  the  following  in  cigarettes: 

I^.      Sodii   arsenat 3ss  to  j         2  .  to  4  .  gm. 

Aquae  destillat §i  30.  c.c. 

M.  S. — Moisten  unsized  white  paper,  and  roll  into  ciga- 
rettes, each  containing  gr.  1/4  to  j  of  the  salt.  Two  or  3 
of  these  should  be  inhaled  daily. 

Trousseau's  cigarettes  are: 

I^.      Belladonnae  fol 3i  4.  gni. 

Stramonii  fol. 

Hyoscyami aa    oss  2 .  gm. 

Ext.  opii gr.  iii  .194  gm. 

Aquae  laurocerasi q.  s. 

M.  S. — Dissolve  the  opium  in  the  water  and  moisten  the 
leaves  therewith.  When  dry  roll  into  12  cigarettes.  Smoke 
2  a  day. 

Potter  recommends  the  following  prescription: 

I^.      Ext.  stramonii gr.  ii 

Potass,  iodid ;  .  .  .  .     5iss 

Ammonii  carbonat 5i 

Tr.  lobeliae 5iss 

Aquae  chloroformi.  q.  s.ad    Sviii 
M.  S. — Tablespoonful  every  six  hours. 

The  following  combination  may  be  of  service: 

I^.      Morphin.  sulphat gr.  ss 

Fluidextract.  belladonnas    n^xxxii 
Fluidextract.  grindeliae.  .    f  5ii 

Spt.  etheris  comp f  5iv 

Syrupi q.  s.  ad  f  5ii 

M.  S. — Teaspoonful  as  the  occasion  requires. 


130  gm 

6. 

gm 

4. 

gm 

6. 

c.c. 

480. 

c.c. 

032  gm 

2 

c.c. 

8 

c.c. 

15 

c.c. 

60 

c.c. 

EMPHYSEMA.  545 

During  the  interval  between  the  attacks,  the  nasal  mucous 
membrane  should  be  carefully  examined  and  in  the  presence  of 
morbid  conditions  should  receive  appropriate  treatment.  The 
condition  of  the  heart  and  lungs  should  likewise  be  ascertained, 
The  digestive  tract  should  also  receive  attention.  The  various 
reflex  conditions  that  may  induce  the  paroxysms  should  be 
removed.  Dry  climate  is  usually  most  beneficial.  The  long- 
continued  administration  of  potassium  iodid  and  arsenic  is  of 
special  value.  As  additional  aids  may  be  mentioned  systematic 
exercise  short  of  fatigue,  bathing,  regulated  diet,  and,  when 
possible,  a  change  of  climate. 


DISEASES  OF  THE  LUNGS. 

EMPHYSEMA. 

Synonym. — Vesicular  emphysema. 

Definition. — Dilatation  of  or  increase  in  the  size  and  capacity 
of  the  air-vesicles,  characterized  by  enlargement  or  distention 
of  the  lungs,  difficulty  of  breathing,  especially  on  exertion,  and 
associated  sooner  or  later  with  dilatation  of  the  heart. 

Causes. — The  predisposing  cause  of  emphysema  is  a  heredi- 
tary nutritive  derangement  of  the  lung-structure,  often  asso- 
ciated with  a  rigid  enlargement  of  the  thorax. 

The  exciting  cause  is  either  too  forcible  and  long-continued  in- 
spiration— the  theory  of  inspiration — or  the  excessive  mechani- 
cal distention  of  the  vesicular  walls  by  forced  expiration-— //^^ 
theory  of  expiration.  But  for  either  of  these  theories  to  be 
operative  the  lung-structure  must  be  congenitally  weak,  for  if 
violent  respiratory  efforts  alone  were  the  essential  factor,  the 
disease  would  be  much  more  frequent. 

What  is,  known  as  vicarious  or  compensatory  emphysema  is  a 
distention  of  the  air-cells  of  the  healthy  portion  of  the  lung, 
some  other  part  being  the  seat  of  consolidation. 

Interlobular  emphysem.a  is  the  presence  of  air  in  the  spaces  be- 
tween   the    lobules    of    the    lungs    underneath    the    pulmonary 
pleura. 
35 


546  EMPHYSEMA. 

Ordinary  vesicular  emphysema  is  known  also  as  pseudo-hypcr- 
trophic  emphysema  on  account  of  the  increase  in  the  capacity  of 
the  vesicles,  due  to  distention.  The  walls  of  the  vesicles  are 
atrophic  to  a  greater  or  less  extent. 

Senile  emphysema  is  another  variety;  often  termed  "small- 
lunged  emphysema."  There  is  true  atrophy  of  the  pulmonary 
vesicles,  although  their  capacity   may  be  relatively  increased. 

Pathologic  Anatomy. — The  situation  of  vesicular  emphysema 
is,  in  the  majority  of  cases,  the  superior  portions  of  the  chest, 
and  is  more  marked  on  the  left  side  than  on  the  right. 

An  emphysematous  lung  feels  remarkably  soft  to  the  touch, 
and  upon  cutting,  a  dull,  creaking  sound  is  barely  perceptible. 
It  is  of  a  pale-red  color;  the  vesicular  walls  are  thinner  and 
slighter;  the  vesicles  are  greatly  enlarged,  sometimes  to  the  size 
of  a  pea  or  bean,  and  have  an  irregular  shape,  and  traversing 
most  of  these  large  sacs  (dilated  vesicles)  a  few  delicate  bands, 
the  remains  of  the  lacerated  interalveolar  septa,  are  visible. 
With  the  destruction  of  the  septa  many  of  the  capillaries  are 
destroyed,  leaving  the  emphysematous  tissue  remarkably  blood- 
less and  dry.  In  consequence  of  the  destruction  of  so  many 
of  the  capillaries,  the  obstruction  to  the  pulmonary  circulation 
becomes  so  great  that  the  pulmonary  artery  and  right  cavities 
of  the  heart  are  greatly  distended;  finally  the  muscular  tissue 
of  the  heart  undergoes  granular,  followed  by  fatty,  degenera- 
tion. The  distention  of  the  veins  results  in  a  general  venous 
stasis,  with  nutmeg  liver,  congested  kidneys,  and  gastro- 
intestinal catarrh. 

Symptoms. — The  disease  is  often  not  suspected  until  it  is  well 
developed.  The  chief  symptoms  of  vesicular  emphysema  are 
difficulty  of  breathing  (dyspnea),  greatly  aggravated  on  exer- 
tion; more  or  less  cough,  the  result  of  an  attending  bronchitis, 
and  the  various  symptoms  resulting  from  dilatation  of  the 
heart,  partiularly  cyanosis  without  marked  distress.  The 
discomfort  of  the  patient  is  often  increased  by  paroxysms  of 
asthma. 

Physical  Signs.  Inspection. — The  shoulders  are  rounded, 
the  intercostal  spaces  widened,  and  the  vertical  diameter  elon- 


EMPHYSEMA.  547 

gated,  with  circumscribed  prominences  between  the  clavicles 
and  nipples,  often  increased  by  the  act  of  coughing — the  pecu- 
liar "barrel-shaped"  chest,  characteristic  of  this  disease.  The 
character  of  the  respiratory  movements  is  marked,  there  being 
but  slight  movement  observed  on  forcible  respiration,  the  chest 
having  the  constant  appearance  of  a  full  inspiration. 

Palpation. — The  vocal  fremitus  is  diminished,  and  the  cardiac 
impulse  depressed  and  nearer  to  the  sternum. 

Percussion. — The  resonance  is  increased  (hyper-resonant) 
over  all  the  emphysematous  portions,  and,  if  the  whole  lung  be 
involved,  extends  to  the  seventh  or  eighth  rib  anteriorly  and 
to  the  twelfth  rib  posteriorly.  The  hepatic  dullness  may  not 
begin  until  the  inferior  margin  of  the  ribs  is  reached;  the  cardiac 
dullness  is  lessened,  on  account  of  the  emphysematous  lung 
nearly  covering  the  heart. 

Auscultation. — The  vesicular  murmur  is  weakened,  and  in 
pronounced  cases  almost  absent.  If  bronchitis  be  present,  the 
inspiratory  sound  may  be  rough  or  sibilant  in  character,  but 
its  duration  is  always  shortened.  Expiration  is  always  pro- 
longed, and  if  bronchitis  be  present,  may  be  associated  with 
more  or  less  pronounced  moist  or  bubbling  rales.  The  first 
sound  of  the  heart  is  lessened  in  intensity  and  duration,  the 
second  sound  being  sharply  accentuated. 

Jyidignosis,.— Bronchitis  is  distinguished  from  emphysema  by 
the  absence  of  dyspnea,  hyper-resonance  of  the  chest,  changes 
in  its  shape,  size,  and  movements,  and  the  disturbance  of  the 
circulation. 

Spasmodic  asthma,  by  the  paroxysmal  character  of  the  affec- 
tion, emphysema  being  a  permanent  malady,  with  attacks  of 
asthma. 

Cardiac  diseases  due  to  other  causes  than  emphysema  do  not 
have  the  characteristic  physical  signs  of  that  affection. 

Prognosis. — Vesicular  emphysema  is  essentially  a  chronic 
disease.  In  itself  it  rarely  proves  fatal,  but  if  aggravated  from 
any  cause,  or  if  associated  with  frequent  or  prolonged  asthmatic 
paroxysms,  the  cardiac  changes  are  hastened,  and  general 
dropsy  supervenes,  death  occurring  from  exhaustion,  or,  more 


548  EMPHYSEMA. 

commonly,  as  the  result  of  intercurrent  attacks  of  pneumonia. 

Treatment. — It  being  impossible  to  restore  the  altered  lung- 
structure,  the  indications  for  treatment  are  to  relieve  the  symp- 
toms and  to  endeavor  to  prevent  its  further  progress   . 

For  the  relief  of  the  asthmatic  paroxysms,  morphin  sulphate, 
combined  with  atropin  sulphate,  may  be  used  hypodermically. 
Citrated  caffein,  gr.  ii  to  v  (0.13  to  0.3  gni.),  alone  or  in  combina- 
tion with  nitroglycerin,  strychnin,  or  morphin,  potassium  iodid, 
or  inhalations  of  oxygen,  may  be  employed  for  the  same 
purpose. 

For  the  attacks  of  bronchial  catarrh  the  following  is  of  value : 

I^.      Ammonii  chloridi oij      •  '  8 .  gm. 

Tinct.  hyoscyami f  oiv  1 5  .  c.c. 

Glycerini f  oj  30.  c.c. 

Syr.  prun.  virg. .  .  q.  s.  ad  f5iv  ad.  120.  c.c. 

M.  S. — Half  tablespoonful  every  few  hours,  well  diluted. 

To  prevent  the  progress  oj  the  affection,  remove  the  bronchial 
catarrh,  relieve  the  difficulty  of  breathing,  and  strengthen  the 
cardiac  action;  no  one  combination  seems  comparable  with  the 
following  for  this  purpose : 

I^.      Potassii  iodidi gr.  v  .3       gm. 

Strychninae  sulph gr  1/32  .002  gm. 

Liq.  potassii  arsenit tt|^v  .3       c.c. 

Aq.  lauro-cerasi .  ." f  oj  4.          c.c. 

M.  S. — Four  times  a  day,  well  diluted. 

But  of  all  means  hitherto  proposed  for  the  relief  of  emphysema, 
nothing  has  approached  the  inhalation  of  compressed  air  by 
means  of  the  apparatus  of  Waldenberg.  For  attacks  of  cyanosis 
a  free  venesection  often  saves  life,  combined  with  and  followed 
by  full  doses  of  spirit  of  glonoin  (nitroglycerin).  The  dropsy 
arising  from  failure  of  the  heart  to  compensate  for  the  circula- 
tory derangement  in  the  lungs,  may  be  relieved  for  a  time,  by 
-the  use  of  digitalis  and  strychnin  sulphate,  or  citrated  caffein, 
the  last  two  being  cardiac  and  respiratory  tonics  and  stimulants, 
and  the  caffein  a  diuretic  also. 


HEMOPTYSIS.  549 


HEMOPTYSIS. 


Synonyms. — Bronchial  hemorrhage;  bronchopulmonary  hem- 
orrhage; bronchorrhagia. 

Definition. — The  expectoration  of  pure  or  unmixed  blood, 
usually  of  a  bright-red  color,  following  the  act  of  coughing. 

Causes. — In  the  majority  of  cases,  it  is  the  result  of  tubercular 
deposition  in  the  walls  of  the  minute  bronchial  arteries,  excessive 
cardiac  action,  bronchial  congestion,  or  excessive  bodily  exer- 
tion, straining,  lifting,  or  running.  It  may  also  be  due  to  trau- 
matism, pulmonary  congestion,  gangrene,  infarction,  or  cancer, 
ulceration  of  any  portion  of  the  respiratory  tract,  or  to  rupture 
of  an  aneurysm.  In  very  rare  instances  it  may  be  produced  in 
the  course  of  hemophilia,  purpura,  or  scurvy,  and  may  be  an 
example  of  vicarious  menstruation.  Cases  may  occasionally 
be  observed  in  which  no  cause  can  be  detected. 

Pathologic  Anatomy. — Hemoptysis  rarely  causes  death  in 
itself,  so  that  few  opportunities  for  observing  postmortem 
appearances  are  obtained,  and  when  they  do  occur,  the  location 
of  the  hemorrhage  is  seldom  found.  The  air-passages  are  more 
or  less  filled  with  clotted  blood;  the  mucous  membrane  is 
swollen,  and  of  a  dark-red  color;  rarely,  pale  and  bloodless. 
The  air-cells  contain  blf)od  clots,  or  are  distended  with  air, 
the  bronchi  being  filled  with  clots,  preventing  its  escape. 
Unless  the  clots  are  rapidly  removed  by  expectoration  or 
absorption,  a  secondary  inflammation  develops  around  about 
them. 

Symptoms. — "  Spitting  of  blood"  occurs  suddenly;  rarely,  it  is 
preceded  by  epistaxis,  cardiac  palpitation,  and  some  difficulty  of 
breathing.  It  begins  with  a  sensation  of  warmth  under  the 
sternum,  tickling  in  the  throat,  a  sweetish  taste  in  the  mouth, 
an  attempt  to  remove  which  by  the  act  of  coughing  is  followed 
by  a  warm,  saltish,  bright-red,  frothy  liquid  gushing  from  the 
mouth  and  nose.  The  blood  is  alkaline  in  reaction  and  mixed 
with  air  and  mucus.  The  quantity  of  blood  raised  varies  from 
an  ounce  to  a  pint.  The  appearance  of  the  blood  depresses  the 
individual,  he  becoming  pale,  tremulous,  often  fainting.      The 


550  HEMOPTYSIS. 

attack  may  subside  within  half  an  hour  to  several  hours,  re- 
turning for  several  days,  in  the  meantime  the  expectoration 
being  either  bloody  or  streaked  with  blood.  A  slight  febrile 
reaction,  with  chest  pains,  supervenes  upon  the  hemorrhage, 
the  result  of  the  inflammation  at  the  site  of  the  bleeding, 
which  soon  subsides,  except  when  blood  clots  develop  a 
secondary  pneumonia,  which  may  undergo  the  cheesy  meta- 
morphosis. 

Auscultation  reveals  the  presence  of  coarse,  bubbling  rales  in 
circumscribed  areas  of  the  chest. 

Diagnosis. — From  epistaxis,  or  hemorrhage  from  the  posterior 
nares,  it  is  distinguished  by  the  absence  of  air-bubbles  and  an  in- 
spection of  the  fauces  and  the  nasal  cavities. 

Hematemesis,  or  hemorrhage  from  the  stomach,  differs  from 
hemoptysis  in  the  blood  being  vomited  instead  of  expectorated, 
of  a  dark  color,  clotted,  mixed  with  the  acid  contents  of  the 
stomach,  followed  with  black,  tar-like  stools,  and  the  absence  of 
rales  in  the  chest  (and  see  page  246). 

Exceptions  to  the  above  occur  when  the  blood  from  the  lungs 
is  first  swallowed  and  afterward  raised  by  vomiting,  or  when  the 
hemorrhage  in  the  stomach  is  caused  by  the  erosion  of  a  large 
artery,  the  result  of  ulcer  of  the  stomach;  in  these  cases,  however, 
the  raising  of  blood  is  preceded  by  epigastric  pain  and  the  blood 
is  not  frothy. 

Prognosis. — Hemoptysis,  in  itself,  rarely  terminates  fatally, 
except  in  advanced  phthisis  and  aneurysm,  although  causing 
much  depression;  the  patient  rapidly  recovers,  unless  secondary 
pneumonia  results. 

Treatment. — Perfect  rest  in  bed,  with  the  head  and  shoulders 
elevated  and  absolute  quiet  is  essential.  The  diet  should  be 
bland  and  unirritating,  and  the  drinks  cool,  the  patient  being 
allowed  to  slowly  swallow  small  particles  of  ice.  An  ice-bag 
placed  over  the  chest,  if  it  does  not  cause  chilliness,  is  sometimes 
of  value.  Common  salt,  slowly  dissolved  in  the  mouth,  is  a 
popular  remedy,  and,  while  of  little  or  no  benefit,  serves  to 
occupy  the  attention  of  the  patient  and  friends  until  medical 
advice    is    obtained.     The    hypodermic    injection    of    morphin 


HEMOPTYSIS.  551 

sulphate,  gr.  1/4  (.016  gm.),  combined  with  atropin  sulphate, 
gr.  1/60  (o.ooi  gm.),  will  usually  control  a  hemorrhage  imme- 
diately. The  officinal  spirit  of  nitroglycerin  in  half  minim  to 
minim  doses  every  half  hour,  often  promptly  checks  the  hemor- 
rhage. The  intrapulmonary  pressure  may  be  lowered  and  the 
flow  of  blood  consequently  lessened  by  the  application  of  firm 
ligatures  to  the  limbs.  In  protracted  cases,  saline  purgation 
may  be  of  benefit.  The  following  prescription  may  also  be 
employed : 

I^.      Acidi  gallici gr.  xv  i .     gm. 

Acidi  sulphurici  dil rr^x  .  6  c.c. 

Aquae  cinnamomi f5iv  15.     c.c. 

M.  S. — One  dose;  to  be  given  every  fifteen  or  twenty  min- 
utes. 

Other  drugs,  such  as  fiuidextract  of  matico,  f  5i  (4  c.c), 
fiuidextract  of  hamamelis,  n^xx  to  f  oi  (i  .3  to  4  c.c),  alum,  gr. 
XX  (1.3  gm.),  gallic  acid,  gr.  v  to  x  (0.3  to  0.6  gm),  and  oil  of 
turpentine,  nxv  to  xv  (0.3  to  i  c.c),  frequently  repeated,  have 
been  used  with  success. 

The  hypodermic  injection  of  ergotin,  gr.  x  to  xxx  (0.6  to  2 
gm.),  and  the  internal  administration  of  fiuidextract  of  ergot, 
OSS  to  j  (2  to  4  c.c),  have  also  been  recommended,  but  they  are 
harmful  at  times. 

Inhalations,  by  means  of  the  steam  atomizer,  of  either  Mon- 
sel's  solution,  or  tincture  of  the  chlorid  of  iron,  may  be  of  value 
when  other  means  have  failed.  Da  Costa  advises,  for  frequent 
small  hemorrhages  recurring  daily,  a  combination  of  cupric 
sulphate,  gr.  1/12  (0.005  g^"^-).  ^^^  extract  of  opium,  gr.  1/12 
(0.005  g^"^-))  repeated  as  the  occasion  requires. 

Bartholow  employs  the  following: 

I^.     Plumbi  acetat gr.  xx  ,  1.3       gm. 

Pulv.  digitalis gr.  x  .65     gm. 

Pulv.  opii gr.  v  .324  gm. 

M.     Ft.  pil.  No.  X. 

S. — One  every  four  hours. 


552  CONGESTION    OF    THE    LUNGS. 

The  following  formula  may  be  used  at  times: 

I^.      Aluminis 5i  4 .     gm. 

Sacch.  alb 5ss  2 .     gm. 

Pulv.  ipecac,  comp gr.  xx  1.3  gm. 

M.     Ft.  pulv.  No.  vi. 

S. — One  powder  every  two  hours  (Skoda). 

CONGESTION  OF  THE  LUNGS. 

Synonyms. — Pulmonary  engorgement ;  hypostatic  congestion. 

Definition. — An  increase  in,  or  abnormal  fullness  of,  the  capil- 
laries of  the  air-cells;  active  congestion  when  the  result  of  an 
accelerated  circulation;  passive  congestion  when  caused  by  an 
impeded  outflow  from  the  capillaries. 

Causes. — Active.  Increased  cardiac  action;  overexertion; 
alcoholic  excesses;  mental  excitement;  inhalation  of  cold  or  hot 
air. 

Passive.  Obstruction  to  the  return  circulation.  Dilated 
h^art ;  valvular  diseases ;  low  fevers  (hypostatic  congestion) ; 
Bright's  disease. 

Pathology. — The  congested,  or  engorged  lung,  has  a  bloated, 
dark-red  appearance;  its  vessels  are  distended  to  the  uttermost, 
the  tissues  succulent  and  relaxed,  blood  flowing  freely  over  the 
cut  surface;  a  bloody,  frothy  liquid  is  present  in  the  bronchi, 
and  the  alveolar  walls  are  so  much  swollen  that  the  condensed 
lung  show-s  scarcely  any  indication  of  its  cellular  structure, 
resembling  the  tissue  of  the  spleen  {s plenification) . 

Symptoms.- — Active  congestion  precedes  inflammatory  pulmon- 
ary conditions,  and  is  characterized  by  rapidly  developing 
thoracic  distress  and  difficult  breathing,  flushed  face,  strong, 
full  pulse,  throbbing  carotids,  cardiac  palpitation,  congested 
eyes,  and  a  short,  dry  cough,  followed  by  scanty,  frothy  ex- 
pectoration, slightly  streaked  with  blood.  The  presence  of 
fever    indicates    subsequent    inflammation    or    pneumonia. 

Passive  congestion  develops  slowly  with  difficulty  in  breathing, 
blueness  of  the  body-surface,  and  an  almost  continuous  hacking 
cough,  followed  by  scanty,  blood-streaked,  expectoration. 


EDEMA    OF    THE    LUNGS.  553 

Physical  Signs. — Percussion  shows  the  resonance  of  the  lungs 
slightly  diminished,  the  quality  of  the  sound  being  somewhat 
tympanitic.  Auscultation  reveals  diminution  of  the  vesicular 
murmur  and  the  presence  of  subcrepitant  rales. 

Duration. — Active  congestion  lasts  from  three  to  five  days, 
terminating  in  resolution,  hemorrhage,  or  pneumonia.  The 
onset  may  be  so  severe  and  overwhelming  that  death  rapidly 
supervenes.  Passive  congestion  develops  slowly  and  is  sub- 
ject  to   many  and   great   variations,   depending  on   the   cause. 

Diagnosis. — Active  congestion  of  the  lungs  cannot  be  distin- 
guished from  the  stage  of  engorgement  of  a  true  pneumonia. 

Prognosis. — An  acute  congestion  of  the  lungs  may  prove 
fatal  within  a  few  hours,  but  under  prompt  treatment  it  gener- 
ally terminates  favorably. 

The  passive  form  is  controlled  entirely  by  the  cause. 

Treatment. — In  active  congestion  in  strong  and  vigorous  indi- 
viduals, ice-bags  and  wet  cups  applied  to  the  chest,  or  venesec- 
tion can  be  recommended.  The  internal  administration  of 
tincture  of  aconite,  rrLijss  to  v  (0.15  to  0.3  c.c),  every  half  hour, 
and  saline  cathartics  is  also  beneficial  in  such  cases.  Rest  in 
bed  is  essential  in  all  cases. 

In  passive  congestion  in  addition  to  treatment  directed  to- 
ward the  underlying  cause,  there  should  be  dry  or  wet  cups 
applied  to  the  chest,  and  hydra  go  gue  cathartics,  digitalis,  and 
strychnin  administered.  If  much  depression  is  present,  stim- 
ulants are  indicated. 

EDEMA  OF  THE  LUNGS. 

Synonym. — Pulmonary  edema. 

Definition. — An  exudation  of  serum  into  the  pulmonary  inter- 
stitial tissue  and  the  alveoli  of  the  lungs;  characterized  by 
dyspnea,   cough,   and  a  frothy,   blood-streaked  expectoration. 

Causes. — Pulmonary  edema  is  the  result  of  stasis,  occurring 
when  the  outflow  of  venous  blood  in  the  lung  meets  an  obstacle 
that  cannot  be  overcome  by  the  right  ventricle,  as  in  cardiac 
diseases,  in  which  the  left  ventricle  fails,  Bright's  disease,  and 


554  EDEMA    OF    THE    LUNGS. 

alcoholic  excesses,  causing  cardiac  depression.  It  may  be  a 
sequel  to  other  lung  inflammations. 

Pathologic  Anatomy. — The  lung-tissue  is  swollen,  and  does 
not  collapse  when  the  chest  is  opened.  The  elasticity  of  the  tis- 
sue has  disappeared,  and  it  pits  upon  pressure.  If  following 
acute  congestion  of  the  lungs,  the  color  is  red;  if  a  symptom  of 
a  general  dropsy,  its  color  is  pale.  On  cutting  into  the  edema- 
tous spots,  an  enormous  quantity  of  albuminous  fluid,  some- 
times clear,  at  other  times  of  a  red  color,  mixed  more  or  less 
with  blood,  flows  over  the  cut  surface.  The  liquid  is  filled  with 
bubbles,  is  frothy,  from  being  copiously  mixed  with  air,  provid- 
ing the  air-cells  have  not  been  entirely  filled  with  serum,  thereby 
excluding  the  air. 

Symptoms. — The  preeminent  symptom  is  dyspnea,  the  breath- 
ing being  hurried,  labored,  and  rattling,  all  the  accessory 
muscles  of  respiration  being  called  into  action.  The  sense  of 
oppression  and  anxiety  is  extreme.  There  is  also  a  constant, 
harassing,  short  cough,  and  the  expectoration  is  a  blood- 
streaked,  frothy  mucus.  The  action  of  the  heart  may  be 
tremulous  or  feeble.  The  face  is  at  first  flushed,  but  as  the 
left  ventricle  fails,  or  if  the  effusion  into  the  air-cells  be  sufficient 
to  prevent  the  entrance  of  air,  symptoms  of  cyanosis  rapidly 
supervene,  the  pulse  becoming  feeble,  the  surface  cold,  the 
breathing  shallow  and  hurried,  and  the  cough  suppressed, 
stupor  replacing  the  restlessness,  soon  deepening  into  coma. 

Physical  Signs. — Percussion  reveals  no  change  in  the  percus- 
sion-note in  the  absence  of  other  lung  diseases  except  slight  im- 
pairment. Auscultation  demonstrates  weak  breath  sounds, 
and  subcrepitant  and  bubbling  rales. 

Diagnosis. — Acute  pneumonia  in  the  earlier  stages  is  the 
only  condition  likely  to  be  confounded  with  edema  of  the 
lungs,  but  as  the  two  diseases  progress,  the  picture  of  pulmonary 
edema  is  so  characteristic  that  it  cannot  be  mistaken. 

Prognosis. — Grave,  and  particularly  if  occurring  in  pneumonia, 
cardiac,  or  Bright's  disease.  In  the  majority  of  instances  it 
is  a  terminal  symptom  coming  on  in  all  forms  of  acute  and 
chronic  diseases. 


BRONCHOPNEUMONIA.  555 

Treatment. — As  a  rule  remedies  are  useless  The  indication 
is  to  maintain  the  heart,  and  this  may  be  produced  by  the 
hypodermic  injection  of  atropin  sulphate,  gr.  1/60  (0.00 1  gm.), 
repeated  as  necessary,  strychnin  sulphate,  gr.  1/24  (0.0035 
gm.),  repeated  every  half-hour,  citrated  caffein,  gr.  iii  to  v 
(0.2  to  0.3  gm.),  spartein  sulphate,  gr.  i  to  ii  (0.065  to  0.13  gm.), 
every  hour  or  two,  or  digitalin,  gr.  1/60  to  1/30  (0.00 1  to  0.002 
gm.),  every  two  hours.  Two  or  more  of  these  drugs  may  be 
combined  with  advantage  Occasionally  relief  follows  a  free 
venesection  or  the  application  of  wet  cups  to  the  chest.  Purga- 
tion with  hydragogue  cathartics  is  a  useful  adjunct  to  the 
treatment.  Alcoholic  stimulants  and  ammonia  are  also  valu- 
able. Counterirritation,  ice  poultices,  hot  foot-baths,  diuretics, 
and  inhalations  of  oxygen  may  be  employed. 

BRONCHOPNEUMONIA. 

Synonyms. — Catarrhal  pneumonia;  lobular  pneumonia;  capil- 
lary bronchitis. 

Definition. — An  acute  catarrhal  inflammation  of  the  bron- 
chioles and  alveoli  of  the  lungs,  characterized  by  fever,  cough, 
dyspnea,    copious    expectoration,    and    great    depression. 

Causes. — It  may  be  due  to  an  extension  downward  of  a 
bronchial  catarrh,  or  it  may  follow  one  of  the  infectious  fevers, 
especially  measles,  influenza,  and  whooping  cough.  Persons 
of  the  rachitic  or  scrofulous  diathesis,  in  whom  there  is  a  greater 
irritability  of  the  epithelial  elements,  are  particularly  pre- 
disposed to  this  form  of  pneumonia  on  slight  exposure.  It 
may  also  be  due  to  influenza  or  heart  disease.  The  affection 
is  observed  most  frequently  in  childhood  and  old  age.  The 
inspiration  of  particles  of  food  and  mucus,  such  as  occurs  in 
palsies,  uremia,  last  stages  of  low  diseases,  etc.,  induces  pneu- 
monia of  the  catarrhal  type  (aspiration  or  deglutition  pneumonia) . 

The  exciting  cause  is  a  microorganism  or  group  of  micro- 
organisms. Mixed  infection  is  the  common  condition.  The 
organisms  found  with  greatest  frequency  are  the  micrococcus 
lanceolatus,    the    streptococcus    pyogenes,    the    staphylococcus 


556  BRONCHOPNEUMONIA. 

aureus  and  albus,  and  Friedlander's  bacillus.  In  some  cases, 
the  colon  bacillus,  the  typhoid  bacillus,  Klebs-Loffler  bacillus, 
or  the  bacillus  of  pneumonia  may  be  demonstrated. 

Pathologic  Anatomy. — The  earliest  change  is  hyperemia  of 
the  mucous  membrane  of  the  bronchi,  extending  to  the  con- 
nective tissue  of  the  bronchioles  and  accompanying  arterioles 
and  to  the  alveoli,  with  swelling  and  succulence  of  these  tissues, 
accompanied  by  an  abnormal  secretion  and  an  immense  produc- 
tion of  young  cells  from  the  proliferation  of  the  bronchial  and 
alveolar  epithelium,  admixed  with  a  yellowish,  creamy,  mucoid 
material,   which  blocks  up  the  bronchioles  and  air-cells. 

Both  lungs  are  involved,  and  on  section  scattered  areas  of 
consolidation  are  observed  surrounding  the  finer  bronchioles. 
Collapsed  areas  ma}^  be  noticed  in  addition,  due  to  obstruction 
of  the  bronchi.  The  terminal  bronchi  are  found  filled  with 
a  purulent  exudate.  This  exudate  and  the  infiltrate  in  the 
lung-tissue  are  made  up  of  desquamated  epithelium  and  leu- 
kocytes 

The  affected  parts  first  have  a  reddish-gray,  soon  changing 
to  a  yellowish-gray,  color,  due  to  the  rapid  metamorphosis  of 
the  newly  developed  cells.  If  the  fatty  change  be  completed, 
absorption  takes  place  and  the  consolidation  is  removed;  if 
it  remains  incomplete,  the  cells  atrophy,  the  little  mass  becoming 
caseous,  and  the  disease  passes  into  a  chronic  state. 

The  bronchial  tubes  also  participate  in  the  disease;  the  walls 
become  thickened  from  a  hyperplasia  of  the  connective 
tissue    {peribronchitis),    and    their    caliber    is    often    increased. 

Symptoms. — Catarrhal  pneumonia  begins  as  a  catarrhal  bron- 
chitis. It  may  be  either  acute,  subacute,  or  chronic  in  its 
course. 

Acute  variety:  Its  onset  is  announced  by  a  gradual  rise  of 
temperature  to  102°  to  103°  F.,  the  febrile  phenomena  assum- 
ing a  typical  remittent  character,  with  rapid,  laborious,  and 
shallow  breathing,  as  shown  by  the  widely  dilated  nares  and 
violent  action  of  all  the  accessory  muscles,  while  the  insufficient 
distention  of  the  lungs  is  shown  by  the  great  recession  of  the 
lower  part  of  the  chest -walls  and  sinking  in  of  the  intercostal 


BRONCHOPNEUMONIA.  557 

Spaces.  The  inspiration  is  short  and  imperfect,  the  expira- 
tion noisy  and  prolonged;  the  pulse  is  frequent,  loo  to  120  or 
more,  and  somewhat  compressible;  the  cough,  which  during 
bronchitis  was  loose,  now  becomes  short,  hacking,  dry,  and 
painful,  soon  followed  by  more  or  less  copious  muco-purulent 
expectoration;  the  appetite  is  impaired,  the  bowels  somewhat 
loose,  the  urine  scanty  and  high-colored,  and  the  surface  fre- 
quently covered  with  a  more  or  less  profuse  perspiration. 

The  subacute  and  chronic  varieties  have  the  same  general 
symptoms,  but  the  duration  is  longer  and  the  exhaustion 
greater. 

The  progress  of  catarrhal  pneumonia  is  sometimes,  although 
not  often,  a  very  acute  one.  The  disease  may  prove  fatal  in  a 
few  days,  especially  if  it  attacks  feeble  children;  in  such  cases 
the  countance  becomes  pale  and  livid,  the  lips  bluish,  the  eyes 
dull,  and  a  restlessness  supervenes,  giving  place  to  apathy  and 
a  continually  augmented  somnolence. 

Resolution,  when  it  occurs,  is  by  lysis,  several  weeks  elapsing 
before  complete  recovery. 

Physrcal  Signs. — Percussion  yields  dullness  in  scattered  areas 
over  both  lungs,  the  intervening  healthy  lung  often  giving  a 
more  or  less  hollow  or  tympanitic  note. 

Auscultation  reveals  vesiculo-bronchial  breathing,  changing 
to  moist  bronchial  breathing,  associated  with  small  bubbling 
(subcrepitant)  rales.  As  the  disease  progresses  toward  resolu- 
tion, the  rales  become  larger  (larger  bubbling)  and  more  nu- 
merous. If  pneumonic  phthisis  result,  physical  signs  indica- 
tive of  that  condition  are  soon  evident. 

Sequelae. — Attacks  of  catarrhal  pneumonia  complicated 
with  atelectasis  or  collapse  of  the  lobules,  when  recovery  occurs, 
are  followed  by  emphysema  of  the  lungs. 

If  the  catarrhal  products  which  fill  the  .  alveoli  and  bron- 
chioles and  intervening  connective  tissue  do  not  rapidly  under- 
go complete  fatty  metamorphosis  and  consequent  absorption, 
pneumonic  phthisis  results. 

Diagnosis. — Ordinary  bronchial  catarrh  differs  from  broncho- 
pneumonia by  the  absence  of  dyspnea,  fever,  and  dullness  on 


558  BRONCHOPNEUMONIA. 

percussion,  and  the  presence  of  the  large  bubbHng  rales,   and 
also  by  the  subsequent  history  of  the  two  affections. 

Lobar  pneumonia  is  a  unilateral  disease;  bronchopneumonia 
is  bilateral  and  diffused  over  both  lungs — the  former  a  self- 
limited  disease,  the  latter  having  no  fixed  duration.  Lobar 
pneumonia  is  characterized  by  acute  onset,  high  fever  termin- 
ating usually  by  crisis  within  ten  days,  and  distinct  physical 
signs,  indicating  uniform  consolidation. 

Acute  tuberculosis  at  its  onset  is  characterized  by  the  presence 
of  a  capillary  bronchitis,  a  differentiation  being  possible  only 
by  a  study  of  the  clinical  history  and  course  of  the  two  maladies, 
and  the  presence  of  the  tubercle  bacilli  in  the  former. 

Edema  of  the  lungs  is  a  bilateral  disease  associated  with  a 
short,  dry  cough,  and  dyspnea,  but  lacks  the  previous  catarrhal 
history  and  high  temperature  of  catarrhal  pneumonia. 

Prognosis.- — Fully  one-half  of  the  cases  of  true  catarrhal  pneu- 
monia terminate  fatally.  The  prognosis  must  be  guarded  in 
scrofulous  or  rachitic  subjects,  or  those  enfeebled  by  other 
diseases,  for,  unless  prompt  resolution  can  be  effected,  it  will 
terminate  fatally  early,  or  develop  pneumonic  phthisis. 

Treatment. — Confinement  to  bed  is  paramount,  but  the  posi- 
tion of  the  patient  is  to  be  frequently  changed.  The  diet  must 
be  of  the  most  nutritious  character,  administered  at  frequent 
intervals;  milk,  eggs,  chicken,  beef,  mutton  and  oyster  broths 
are  the  most  suitable  articles.  The  steady  use  of  brandy  or 
whiskey  throughout  the  attack  is  of  importance,  regulating  the 
amount  by  the  age  of  the  patient  and  the  severity  of  the  attack. 

Locally,  a  weak  mustard  plaster  followed  with  a  cotton- 
batting  jacket  is  valuable.  Poultices  are  of  little  use.  The 
febrile  symptoms  and  'early  cough  are  often  modified  by  the 
following  mixture: 

I^.     Potassii  citratis 5vj  24 .  gm. 

Spt.  aetheris  nitrosi 5iv  15.  c.c. 

Tinct.  opii  camphorat .  .  .     5iv  15.  c.c. 
Liquor,    potassii    citratis 

q.  s.  ad    5vj  ad  180,  c.c. 

M.  S. — Dessertspoonful  every  three  hours. 


FIBROID    PNEUMONIA.  559 

Early  in  an  attack,  with  high  temperature  in  children, tincture 
of  aconite,  in  small,  frequently  repeated  doses  is  valuable.  If 
the  fever  persists,  a  combination  of  phenacetin  or  antifebrin 
with  camphor  or  digitalis  is  useful.  The  ice-bags  or  poultices 
are  as  strongly  recommended  for  bronchopneumonia  as  for 
lobar  pneumonia,  and  in  sthenic  cases  should  be  given  a  trial. 

For  the  catarrhal  process,  the  air  of  the  apartment  should  be 
maintained  at  an  even  temperature  and  moistened  by  disen- 
gaging the  vapor  of  water  in  it.  The  following  combination  is 
of  great  utility  in  nearly  all  cases,  regulating  the  dose  in  accord- 
ance with  the  age  of  the  patient : 

1^.      Ammonii  carbonat gr-  v  .3  gm. 

Potassii  iodidi gr.  v  .3  gm. 

Mucil.  acaciae q.  s.  q.  s. 

Mist,  glycyrrh.  comp  .  .  .  .  5j  4-  C-c 

Syr.  prun.  virg.  .  .q.  s.  ad  5  iv  ad  15.  c.c. 
M.   S. — Every  three  hours. 

A  more  pleasant  way  of  administering  the  ammonium  salts  is 
in  capsules,  each  containing  about  2  1/2  gr.  of  each  salt  with  an 
aromatic  oil.  Terpin  hydrate  acts  remarkably  well  in  many 
lingering  cases.  The  aromatic  spirit  of  ammonia  in  either 
chloroform  water  or  cherry -laurel  water  makes  an  excellent  mild, 
stimulating  expectorant. 

During  convalescence,  tonics  such  as  iron,  cod-liver  oil,  syrup 
of  the  iodid  of  iron,  etc.,  and  good  food  are  indicated. 

FIBROID    PNEUMONIA. 

Synonyms. — Chronic  interstitial  pneumonia;  cirrhosis  of  the 
lung. 

.Fibroid  pneumonia  is  a  chronic  disease  of  the  lungs,  character- 
ized by  a  marked  overgrowth  of  connective  tissue,  or  cirrhosis; 
this  overgrowth  contracts  later  on  and  causes  a  diminution  of 
air  space.  It  may,  in  rare  instances,  follow  croupous  or  ca- 
tarrhal pneumonia  and  chronic  pleurisy.  Inhalation  of  irritant 
particles  of  dust,  stone,  coal,  etc.,  over  a  long  period,  are  common 


560  PLEURISY. 

causes.  It  is  in  most  cases  due  to  tuberculosis,  but  also  arises 
independently  of  that  affection.  The  signs,  symptoms,  and 
morbid  anatomy  of  fibroid  pneumonia  and  fibroid  phthisis  are 
the  same,  with  the  exception  that  the  tubercle  bacillus  may  be 
demonstrated  in  the  sputum  of  the  latter  (see  Fibroid  Phthisis) . 


DISEASES  OF  THE  PLEURA. 
PLEURISY. 

Synonyms. — Pleuritis;  "stitch  in  the  side." 

Definition. — A  fibrinous  inflammation  of  the  pleura,  either 
acute,  subacute,  or  chronic  in  character,  occurring  either  idiopath- 
ically  or  secondarily;  characterized  by  a  sharp  pain  in  the  side,  a 
dry  cough,  dyspnea,  and  fever.  It  may  be  limited  to  a  part,  or 
may  involve  the  whole  of  one  or  both  pleural  membranes. 

Causes. — Idiopathic  pleurisy  is  said  to  be  due  to  cold  and  ex- 
posure, to  injuries  of  the  chest  walls,  or  muscular  exertion. 
Tuberculosis  is  the  cause  in  a  few  instances. 

Secondary  pleurisy  occurs  during  an  attack  of  pneumonia,  peri- 
carditis, rheumatism,  variola,  scarlatina,  measles,  Bright's 
disease,  tuberculosis,  or  puerperal  fever. 

Chronic  pleurisy  follows  an  acute  attack,  or  is  the  result  of 
tuberculosis,  Bright's  disease,  cancer,  or  alcoholism. 

Pathology. — As  in  inflammation  of  other  serous  membranes 
there  are  five  stages — hyperemia,  exudation,  effusion,  absorp- 
tion, and  adhesions. 

The  first  stage  is  marked  by  congestion  and  irregularly  diffused 
redness  of  the  membrane  with  scattered  flakes  of  exudation. 
The  second  stage  is  characterized  by  the  copious  formation  of 
lymph,  which  more  or  less  completely  covers  the  membrane, 
giving  it  a  dull,  cloudy,  or  shaggy  appearance.  If  the  inflamma- 
tion ceases  at  this  period,  it  is  termed  dry  pleurisy.  If  the  condi- 
tion progresses  an  effusion  is  poured  out  into  the  pleural  cavity, 
which  may  be' serofibrinous,  fibrinous,  or  purulent.  The  sero- 
fibrinous  variety    is   most   frequent   and   consists   of   a    straw- 


PLEURISY.  561 

colored  fluid  containing  fibrinous  flocculi,  blood,  and  epithelial 
cells.  Its  quantity  is  usually  rather  large.  When  the  exudate 
is  fibrinous,  the  amount  is  small  and  the  consistency  is  greater 
than  that  of  the  preceding.  It  undergoes  organization  quickly 
and  gives  rise  to  adhesions  and  pleural  thickening.  The  exu- 
date becomes  purulent  (empyema)  only  as  the  result  of  micro- 
organismal  infection.  The  effusion  may  become  bloody  in 
some  instances  as  the  result  of  ulceration  (tuberculous  or  can- 
cerous) and  grave  blood  diseases.  Displacement  of  the  viscera 
is  common  in  this  stage  |  if  on  the  right  side,  the  effusion  pushes 
the  heart  farther  to  the  left;  if  on  the  left  side,  the  heart  is 
displaced  to  the  right,  the  impulse  often  being  seen  to  the  right 
of  the  sternum.  The  lungs  are  also  compressed  and  displaced 
upward  and  against  the  spinal  column.  On  removal  of  the 
fluid  they  again  expand,  except  in  cases  of  chronic  pleurisy, 
in  which  the  adhesions  interfere  with  the  functional  activity 
of  the  pulmonary  structure.  Absorption  of  the  effused  material 
is  the  natural  sequence  in  most  cases.  Unabsorbed  portions 
undergo  organization,  producing  adhesions,  which,  in  extreme 
instances  may  obliterate  the  entire  pleural  cavity.  Sacculation 
of  the  effusion  by  adhesions  is  not  uncommon,  especially  in 
purulent  exudations  in  which  the  adhesions  form  an  abscess 
wall.  Varying  degrees  of  adhesion  of  the  opposing  pleural 
surfaces  are  encountered,  depending  on  the  character  of  the 
exudate. 

Chronic  pleurisy  results  when  the  fluid  is  not  absorbed  or  when 
it  is  effused  into  the  cavity  very  slowly.  The  membrane  is  ir- 
regularly thickened  and  firm  adhesions  are  formed  within  the 
meshes  of  which  the  fluid  is  found.  Retraction  of  the  thoracic 
wall  may  be  observed.  If  the  fluid  is  pus,  it  may  rarely  be- 
come inspissated  and  encapsulated,  or  it  may  rupture  through 
the  chest  wall,  discharging  externally  through  a  fistula,  or  it 
may  rupture  into  the  bronchi  or  in  very  rare  instances  into  the 
intestines. 

Symptoms. — The  acute  variety  begins  with  a  chill,  followed  by 
a  sharp  lancinating  pain  (stitch)  near  the  nipple  or  in  the 
axilla,  aggravated  by  coughing  and  breathing,  and  associated 
36 


562  PLEURISY. 

with  slight  tenderness  on  pressure.  The  respirations  are  rapid 
and  shallow,  30  to  35  per  minute,  and  there  are  present  a  short, 
dry,  hacking  cough,  moderate  fever,  and  compressible  pulse 
(90  to  120).  With  the  effusion  of  liquid,  the  pain  diminishes; 
dyspnea  becomes  more  aggravated;  cyanosis  develops;  the 
cough  becomes  distressing;  and  the  cardiac  action  greatly 
embarrassed,  the  countenance  wearing  an  anxious  expression. 
The  patient  usually  lies  on  the  affected  side.  With  the  absorp- 
tion of  the  fluid  the  symptoms  gradually  ameliorate,  convales- 
cence being  rather  rapid  in  simple  cases. 

The  subacute  variety  begins  insidiously  after  cold,  exposure, 
and  fatigue,  in  individuals  enfeebled  from  various  causes.  The 
patients  usually  complain  of  a  sense  of  weariness,  shortness  of 
breath,  aggravated  on  exertion,  evening  fever,  followed  by 
night-sweats,  and  a  short  harrassing  cough,  with  little  or  no 
expectoration.  The  pulse  is  small,  feeble,  but  frequent,  100  to 
120  beats  per  minute.  The  characteristic  pain  in  the  side  of 
acute  pleurisy  is  absent. 

The  chronic  variety  is  characterized  by  a  more  prolonged  course, 
irregular  chills,  fever,  night-sweats,  dyspnea,  palpitation,  embar- 
rassed circulation,  and  more  or  less  prostration. 

Physical  Signs. — Inspection  during  the  early  stage  serves  to 
detect  deficient  movement  of  the  affected  side  on  account  of  the 
pain  induced  by  full  breathing.  After  the  effusion  has  formed 
there  will  be  observed  bulging  or  fullness  of  the  affected  side,  with 
obliteration  of  the  intercostal  spaces  and  displacement  of  the 
cardiac  impulse. 

Palpation  demonstrates  feeble,  or  absence  of,  vocal  fremitus 
over  the  effusion,  with  exaggeration  of  the  same  above  the  fluid. 
The  affected  side  is  immobile,  and  very  rarely  fluctuation  may  be 
obtained. 

Percussion  during  the  early  stage  yields  a  slightly  impaired 
note.  Later,  dullness  or  even  flatness,  with  increased  resistance 
may  be  obtained  directly  over  the  fluid,  while  above  the  effusion 
the  percussion-note  is  tympanitic.  The  line  of  demarcation 
is  higher  behind  than  in  front.  Effusion  of  the  left  pleural 
cavity  obliterates  Traube's  semilunar  space.     The  fluid  changes 


PLEURISY.  563 

its  level  with  different  positions  of  the  body  and  the  area  of 
dullness  is  correspondingly  movable. 

Auscultation  reveals  during  the  early  stage  a  feeble  vesicular 
murmur  over  the  affected  side,  the  patient  breathing  lightly  to 
prevent  pain.  A  friction  sound,  slight  and  grating  or  creaking, 
becoming  louder  as  the  exudation  of  lymph  increases,  limited 
usually  to  the  angle  of  the  scapula  of  the  affected  side,  rarely 
over  the  entire  side,  accompanies  the  respiratory  movements. 
During  the  stage  of  effusion,  the  vesicular  murmur  is  feeble  or 
absent  on  the  affected  side  depending  upon  partial  or  complete 
compression  of  the  lung  by  fluid.  Above  the  effusion,  puerile 
breathing  is  heard,  and  just  at  the  upper  margin  of  the  fluid  a 
friction  sound  may  be  heard.  Vocal  resonance  is  diminished 
or  absent  over  the  fluid  and  markedly  increased  above  the 
effusion,  egophony  being  obtained  at  its  upper  margin.  With 
the  absorption  of  the  fluid,  the  vesicular  murmur  and  the  moist 
friction  sound  gradually  return. 

Diagnosis. — Acute  pneumonia  may  be  distinguished  from 
pleurisy  by  the  pronounced  chill,  high  fever,  rusty  sputum,  in- 
creased tactile  fremitus,  bronchial  breathing,  fine,  crackling, 
inspiratory  rales,  increased  vocal  resonance,  fixed  dullness, 
absence  of  intercostal  bulging,  and  the  absence  of  cardiac  dis- 
placement. 

Rheumatisin  of  the  intercostal  muscles,  or  pleurodynia  is  char- 
acterized by  more  diffuse  pain  and  tenderness.  The  physical 
signs  are  negative. 

Enlargement  of  the  liver  may  be  mistaken  for  pleurisy  with  effu- 
sion, the  chief  point  of  distinction  being  that,  in  enlargement  of 
the  liver,  the  superior  line  of  dullness  is  depressed  upon  full 
inspiration,  while  in  pleurisy,  with  effusion,  inspiration  does  not 
modify  the  location  of  the  dullness. 

Pericarditis  with  effusion  is  attended  by  physical  signs  limited 
to  the  precordium  and  symptoms  referable  to  embarrassed 
circulation. 

Km,pyema  is  attended  by  septic  phenomena  in  addition  to 
physical  signs  indicating  pleural  effusion.  High  and  irregular 
fever,  chills,  sweats,  and  leukocytosis  are  present.     Aspiration 


564  PLEURISY. 

yields  pus  and  pus-producing  microorganisms.  Also  the 
whispered  voice  is  inaudible  over  pus,  while  it  can  be  heard  over 
serous  fluid  {Baccellts  sign). 

Hydrothorax  may  be  distinguished  by  its  previous  history,  the 
absence  of  pain  and  fever,  and  on  aspiration  the  withdrawal  of 
an  albuminous  fluid  of  low  specific  gravity. 

Prognosis. — Idiopathic  pleurisy  usually  terminates  in  re- 
covery within  three  weeks.  Pleurisy,  the  result  of  constitu- 
tional causes,  has  its  progress  modified  by  the  condition  with 
which  it  is  associated.  Empyema,  unless  the  result  of  a  diathe- 
sis, terminates  favorably  with  prompt  treatment.  Double 
pleurisy  is  unfavorable.  The  etiologic  factor  of  tuberculosis 
must  always  be  borne  in  mind  in  making  a  prognosis  in  pleurisy, 
whether  acute  or  chronic.  When  the  effusion  is  very  large  the 
possibility  of  sudden  death  should  always  be  considered. 

Treatment. — The  patient  should  be  immediately  placed  at 
rest  in  bed  and  the  diet  restricted  to  liquids  or  semisolid  sub- 
stances. The  administration  of  fractional  doses  of  calomel, 
followed  by  a  saline,  should  begin  the  medication.  At  the  onset, 
in  robust  individuals,  wet  cups  should  be  applied  to  the  affected 
side  to  relieve  the  pain;  if  the  pain  is  very  severe,  the  dyspnea 
great,  and  the  arterial  tension  high,  venesection  may  be  em- 
ployed. In  anemic  and  weak  individuals  dry  cups  should  be 
used.  Either  wet  or  dry  cups  should  be  followed  by  the  applica- 
tion of  poultices  or  turpentine  stupes.  Severe  pain  is  promptly 
relieved  by  the  hypodermic  injection  of  morphin  sulphate  gr.  i  /6 
(,oi  gm.)  repeated  as  necessary,  or  by  the  internal  administration 
of  small  doses  of  Dover's  powder.  Strapping  the  affected  side 
by  means  of  broad  strips  of  adhesive  plaster  is  of  benefit  in  all 
cases.  In  the  very  early  stages,  the  disease  may  be  cut  short 
to  some  extent  by  the  administration  of  sodium  salicylate,  gr. 
XV  to  XX  (i  to  1.3  gm.),  well  diluted,  every  three  or  four  hours. 
The  salicylates  are  also  useful  during  the  stage  of  effusion. 
After  effusion  has  begun,  fiuidextract  of  pilocarpin,  nxxv  (i  c.c), 
every  two  or  three  hours,  or  in  dram  doses  every  other  day  for 
a  week  or  two,  and  later  twice  weekly,  or  the  following  should 
be  administered: 


PLEURISY.  565 

1^.     Potassii  acctat gr.  xxx  2.  gm. 

Infus.  digitalis oij  8.  c.c. 

M.  S. — Every  three  or  four  hours. 

Matthew  Hay,  of  Scotland,  employs  a  concentrated  solution 
of  magnesium  sulphate  for  the  removal  of  the  effusion.  He 
advises  that  the  patient  should  take  nothing  after  the  evening 
meal,  and  then  an  hour  or  so  before  breakfast,  the  salt  (from 
3iv  to  vi  (15  to  24  gm.)  to  §i  to  ii  (30  to  60  gm.)  dissolved  in  an 
ounce  or  two  of  water)  is  given,  no  fluids  to  be  used  after  its 
administration.  This  usually  produces  from  four  to  eight 
watery  stools,  without  pain  or  discomfort,  and  also  acts  as  a 
diuretic.  Other  diuretics,  such  as  digitalis,  cafTein,  potassium 
acetate,  and  Basham's  mixture,  may  also  be  employed.  Dia- 
phoretics have  little  or  no  effect  on  the  effusion.  Bowditch 
advocates  early  aspiration.  If  after  three  or  four  days  no 
impression  is  made  upon  the  effusion  by  other  means,  aspiration 
should  be  employed,  and  followed  by  tablespoonful  doses  of 
Basham's  mixture  every  four  hours,  and  an  early  morning  dose 
of  magnesium  sulphate,  §ss  to  i  (15  to  30  gm.),  well  diluted. 
Perhaps  a  better  plan  would  be,  to  be  guided  by  the  duration 
and  character  of  the  effusion,  the  degree  of  dyspnea  and  dis- 
turbance of  the  heart,  and  the  visceral  displacement.  The 
puncture  is  usually  made  in  the  sixth  or  seventh  intercostal 
space  between  the  scapula  and  the  axilla.  If  these  means 
do  not  influence  the  effusion,  potassium  iodid,  gr.  xv  (i  gm.), 
diluted,  should  be  administered  every  four  hours,  and  flying 
blisters  should  be  applied  o%er  the  affected  side,  or  blue  ointment 
(mercurial  ointment)  should  be  rubbed  into  the  armpits, 
groins,  and  over  the  effusion.  Painting  of  the  affected  side  with 
iodin  may  also  be  employed. 

In  chronic  pleurisy,  blisters  and  iodin  should  be  used  locally, 
and  potassium  ^ iodid  alternating  with  Basham's  mixture, 
should  be  administered  internally. 

In  purulent  pleural  effusion  (empyema),  aspiration  is  of  little 
value  except  for  diagnostic  purposes  as  the  pus  reaccumulates. 
Incision  of  the  chest  between  the  fifth  and  sixth  ribs  with  the 
insertion  of  a  drainage-tube  is  then  indicated;  the  pleural  sac 


566      .  HYDROTHORAX. 

should  be  treated  then  as  an  abscess  cavity.  More  drastic 
surgical  measures  are  often  necessary,  such  as  excision  of  one  or 
more  ribs.  Basham's  mixture,  stimulants,  and  quinin  should  be 
given  internally  in  addition. 

HYDROTHORAX. 

Synonym. — Dropsy  of  the  pleura. 

Definition. — The  effusion  of  fluid  into  the  pleural  cavities -(bi- 
lateral), the  result  of  a  general  dropsy  from  renal  or  cardiac 
disease.  The  effusion  consists  of  a  more  or  less  clear  serous 
fluid  which  occupies  both  pleural  sacs.  There  are  no  signs  of 
inflammation. 

Symptoms. — It  is  accompanied  by  dyspnea,  cyanosis,  due  to 
deficient  blood  aeration  from  compression  of  the  lungs,  and  symp- 
toms referable  to  the  primary  disease.  The  physical  signs  are 
those  of  pleural  effusion. 

Diagnosis. — The  history,  bilateral  character,  and  the  absence 
of  pain  and  fever  serve  to  distinguish  it  from  other  pleural  condi- 
tions. 

Prognosis. — This  is  controlled  almost  entirely  by  the  primary 
cause  producing  the  general  dropsy. 

Treatment. — The  pleural  condition  will  necessitate  the 
administration  of  hydragogue  cathartics  and  diuretics;  and  at 
times  aspiration  will  be  required.  Dry  cups  over  the  chest 
may  afford  some  relief. 

PNEUMOTHORAX. 

Synonyms. — Air  in  the  pleural  cavity;  hydropneumo thorax. 

Definition. — The  accumulation  of  air  in  the  pleural  cavities, 
with  the  consequent  development  of  inflammation  of  the  mem- 
branes; characterized  by  sharp  pain,  followed  by  rapidly  devel- 
oping dyspnea  and  cough. 

Causes. — It  generally  results  from  tuberculous  ulcers  perfor- 
ating the  pleura.     Abscess,  gangrene,  and  emphysema  may  be 


PNEUMOTHORAX.  ,  567 

causes.  Perforation  may  take  place  from  the  pleura  into  the 
lung  as  the  result  of  empyema  or  abscess  of  the  chest  wall. 
Direct  perforation  from  without  may  follow  fractures  of  the 
ribs,  penetrating  wounds,  and  severe  contusions. 

Pathologic  Anatomy. — The  gas  in  the  pleural  cavity  consists 
of  oxygen,  carbon  dioxid,  and  nitrogen  in  variable  proportions. 
It  may  fill  the  pleural  sac  completely,  compressing  the  lung,  or 
may  be  limited  by  adhesions.  The  gas  tends  to  excite  inflam- 
mation, the  resulting  effusion  being  either  serous  or  purulent. 

Symptoms. — The  onset  is  abrupt  with  sudden  or  sharp  pain 
in  the  side,  intense  dyspnea,  symptoms  of  collapse,  coldness  of 
the  vSurface,  and  cold  sweats.  These  symptoms  in  many  in- 
stances follow  a  severe  or  violent  paroxysm  of  coughing.  In 
severe  cases  the  acute  pain  and  distressing  dyspnea  are  constant 
until  death. 

Physical  Signs. — Inspection  serves  to  detect  enlargement  of 
the  affected  side,  with  absent  or  diminished  respiratory  move- 
ments. The  intercostal  spaces  are  widened  and  sometimes 
bulged  out  so  that  the  surface  of  the  chest  is  smooth.  The 
apex  beat  is  displaced. 

Palpation  reveals  diminished  tactile  fremitus. 

Percussion  yields  marked  changes  in  the  resonance.  Imme- 
diatel}^-  after  the  rupture,  the  percussion-note  is  hyper-resonant, 
or  even  tympanitic  or  amphoric  in  quality.  If  the  amount  of  air 
in  the  pleural  cavity  becomes  extreme,  there  is  dullness  on  per- 
cussion, associated  with  a  feeling  of  great  resistance  or  density. 
When  effusion  of  blood  occurs,  dullness  is  obtained  over  the 
lower  part  of  the  chest,  hyper-resonant,  or  typanitic  percus- 
sion-note over  the  upper  portions  of  the  chest,  these  sounds 
changing  as  the  patient  changes  position. 

Auscultation  demonstrates  several  characteristic  features. 
The  normal  vesicular  murmur  may  be  diminished  or  absent. 
The  typical  amphoric  respiratory  sound  is  heard  when  the  fistula 
is  open,  usually  associated  with  a  metallic  echo.  The  vocal 
resonance  may  be  diminished  or  absent,  or,  rarely,  it  may  be 
exaggerated,  with  a  distinct  metallic  echo. 

Metallic  tinkling,  or  the  bell  sound,  is  sometimes  distinctly 


568  •     GENERAL   SYMPTOMATOLOGY. 

produced  by  breathing,  coughing,  or  speaking,  after  the  develop- 
ment of  infiammation  of  the  pleura. 

After  the  development  of  pleuritis,  suddenly  shaking  the 
patient  gives  rise  to  a  splashing  sensation,  the  succussion 
sound,  if  both  air  and  fluid  are  present  in  the  pleural  cavity. 

Diagnosis. — The  distinctive  features  of  this  affection  are  the 
history,  situation,  symptoms,  and  physical  signs,  the  careful 
consideration  of  which  will  prevent  errors  in  diagnosis. 

Prognosis. — When  occurring  as  the  result  of  tuberculosis,  the 
prognosis  is  extremely  unfavorable;  rarely,  the  fistulous  open- 
ing is  closed  by  inflammatory  action;  the  case  then  becomes 
one  of  chronic  pleurisy.  Cases  due  to  other  causes  are  less 
grave  but  are  nevertheless  serious. 

Treatment.— Morphin  should  be  administered  hypoder  mically 
at  once,  and  diffusible  stimulants,  ammonia,  alcohol,  ether,  etc., 
given  at  once.  Aspiration  of  the  chest  followed  by  strapping 
may  afford  relief  at  times.  Apart  from  these  simple  pro- 
cedures the  treatment  is  that  of  the  primary  disease. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 
GENERAL  SYMPTOMATOLOGY. 

Motor  Phenomena. — The  motor  disturbances  incident  to 
nervous  diseases  may  be  manifested  as  paralysis  or  loss  of 
motion,  or  as  excessive  motor  discharges  including  convulsions, 
tremors,  and  choreiform  movements. 

Paralysis  involving  a  lateral  half  of  the  body  is  termed  hemi- 
plegia; when  involving  the  body  from  the  waist  down,  par- 
aplegia,   and    when    involving    a    single    member,    monoplegia. 

Paralysis  may  be  irregularly  distributed  and  in  such  cases 
may  be  due  to  localized  disease  of  the  muscles  or  nerves  of  the 
affected  region,  or  to  syringomyelia,  disseminated  lesions  in 
the  motor  area  of  the  brain,  lesions  of  the  basal  ganglia,  and 
poliomyletis  (acute  and  chronic). 

Hemiplegia  usually  results  from  hemorrhage  at  the  base  of  the 


GENERAL   SYMPTOMATOLOGY.  569 

brain  injuring  the  internal  capsule,  corpus  striatum,  or  optic 
thalamus.  The  paralysis  occurs  on  the  opposite  side  of  the 
body.  As  other  causes  of  unilateral  paralysis  may  be  mentioned 
lesions  of  the  motor  cortex,  crus  cerebri,  or  pons,  a  unilateral 
lesion  high  up  in  the  spinal  cord,  and  hysteria. 

Paraplegia  may  be  due  to  multiple  neuritis,  caisson  disease, 
or  hysteria,  but  in  most  cases  is  the  result  of  injury  or  disease 
of  the  spinal  cord  such  as  occurs  in  fracture  or  caries  of  the 
vertebrae,  morbid  growths,  aneurysm,  hemorrhage,  acute 
myelitis,  chronic  myelitis,  Landry's  disease,  and  lateral 
sclerosis.  Injury  to  the  brain  during  delivery  may  induce 
spastic  paraplegia. 

Monoplegia  may  result  from  disease  or  injury  of  a  peripheral 
nerve,  a  focal  lesion  in  the  cortex,  or  from  hysteria. 

Convulsions  may  be  defined  as  general  involuntary  par- 
oxysms of  muscular  contraction.  They  may  consist  of  con- 
tinuous contractions,  tonic;  or  intermittent  contractions, 
clonic.  They  may  be  general  or  local.  They  are  usually 
considered  as  of  three  varieties,  epileptiform,  tetanic,  and 
hy  steroidal. 

Epileptiform  convulsions  may  be  observed  in  epilepsy,  organic 
brain  disease,  cerebral  anemia,  uremia,  and  other  toxemias  such 
as  eclampsia,  infectious  fevers,  etc.,  and  reflex  conditions, 
especially  those  referable  to  the  digestive  tract.  Unconscious- 
ness is  usually  present  and  the  contractions  are  mostly  clonic. 

Tetanic  convulsions  occur  in  tetanus,  tetany,  spinal  men- 
ingitis,   and   strychnin   poisoning.     Consciousness    is   retained. 

Hy  steroidal  convulsions  follow  no  fixed  rule.  Consciousness 
is  never  entirely  lost.  Other  hysteric  manifestations  are  present 
and  the  patient  never  inflicts  injury  upon  herself. 

Tremors  are  involuntary  vibratory  movements  and  are 
produced  by  alternate  contraction  and  relaxation  of  antag- 
onistic muscles.  They  are  observed  most  often  in  the  arms, 
head,  face,  tongue,  and  hands.  They  may  be  coarse  or  fine. 
Tremors  occur  in  chronic  alcoholism,  delirium  tremens,  paraly- 
sis agitans,  and  in  poisoning  by  lead,  mercury,  arsenic,  chloral, 
and     opium.     Neurasthenia,     debility     from     various     causes, 


57©  GENERAL    SYMPTOMATOLOGY. 

senility,  hysteria,  disseminated  sclerosis,  and  paresis  are  ac- 
companied by  tremors.  In  disseminated  sclerosis,  the  tremor 
is  irregular,  jerky,  and  increased  by  voluntary  efforts  to  restrain 
it.  The  tremor  is  absent  during  rest  but  is  brought  about  by 
movement.  In  paralysis  agitans,  it  is  regular  and  rhythmic, 
occurring  both  during  rest  and  movement.  The  tremor  of 
senility  is  exceedingly  fine  and  begins  in  the  hands,  often  ex- 
tending to  the  face.  It  occurs  at  first  only  during  motion, 
disappearing  during  rest.  When  age  is  far  advanced  it  may 
occur  during  both  rest  and  movement. 

Choreiform' movements  are  coarse,  incoordinated,  involuntary 
movements  of  a  jerky  and  irregular  character  usually  separated 
by  short  intervals.  They  may  simulate,  to  some  extent, 
purposeful  movements.  Among  the  causes  may  be  mentioned 
idiopathic  chorea,  Huntingdon's  chorea,  post-hemiplegic  chorea, 
organic  brain  disease,  habit,  hysteria,  reflex  irritation,  etc. 

Athetoid  movements  are  slow,  more  or  less  rhythmic  twisting 
movements  of  the  fingers  and  toes.  They  are  observed  in 
cerebral  palsies  of  children,  after  hemiplegia  in  adults,  and 
poliencephalitis. 

The  gait  may  also  be  taken  as  an  index  of  the  character  of 
the  nervous  condition  present.  The  ataxic  gait  is  especially 
characteristic  of  locomotor  ataxia.  In  it,  the  patient  raises 
the  foot  very  high,  throws  it  outward  and  forward,  and  allows 
it  to  fall  suddenly  to  the  ground  in  an  awkward  manner.  The 
spastic  gait  observed  in  spastic  paraplegia  is  characterized  by 
stiff  movements  of  the  lower  extremities.  The  knees  are  some- 
what flexed  and  approach  each  other,  and  the  toe  drags  on  the 
ground  with  each  step.  The  festinating  gait,  or  the  gait  of 
paralysis  agitans  in  the  later  stages  is  distinguished  by  the 
following  features:  As  the  patient  walks,  the  body  bends 
forward  and  the  steps  follow  each  other  in  rapid  succession 
until  the  patient  falls  or  supports  himself  by  means  of  some 
nearby  object.  After  a  very  short  interval  in  which  equilibrium 
is  obtained,  the  patient  repeats  the  cycle.  The  steppage  gait 
is  that  in  which  the  foot  is  highly  elevated  and  the  toe  turned 
up  in  taking  a  step.      In  bringing  the  foot  down  the  heel  is 


GENERAL   SYMPTOMATOLOGY.  571 

first  placed  on  the  ground.  This  gait  occurs  in  multiple  neuritis. 
Titubation  is  the  term  applied  to  that  gait  in  which  there  is 
considerable  swaggering  and  swaying,  particularly  that  form 
occurring  in  disease  of  the  cerebellum. 

The  reflexes  are  motor  phenomena  to  which  the  attention 
should  always  be  directed  in  considering  diseases  of  the  nervous 
system.  They  are  of  two  kinds:  cutaneous  reflexes  and  tendon 
reflexes. 

The  cutaneous  reflexes  are  superficial  reflexes  and  consist  of 
muscular  contractions  produced  by  irritation  of  the  sensory 
nerves  in  the  skin.  The  contractions  induced  by  tickling  the 
soles  of  the  feet  may  be  mentioned  as  examples.  Various  names 
are  applied  to  these  reflexes  according  to  the  situations  in 
which  they  occur.  Cutaneous  reflexes  may  be  delayed  in 
certain  nervous  diseases,  and  in  others  the  response  to  irrita- 
tion may  be  prompt  and  extend  over  the  entire  body.  They 
are  absent  in  shock,  diseases  of  the  brain  and  spinal  cord  in- 
volving the  reflex  centers,  and  diseases  of  the  peripheral  nerves. 
They  are  increased  in  affections  in  which  there  is  increased 
irritability  of  the  cutaneous  nerves,  as  in  tetanus,  strychnin 
poisoning,  general  neuroses,  etc. 

The  tendon  reflexes  are  the  muscle  contractions  produced  by 
gently  tapping  the  tendons  while  the  corresponding  muscles  are 
placed  slightly  upon  the  stretch.  The  same  effect,  but  of  less 
intensity,  may  be  produced  by  striking  the  adjacent  fascia  and 
periosteum. 

The  knee-jerk  or  patellar  reflex  is  produced  by  striking  the  ten- 
don of  the  quadriceps  extensor  muscle  between  the  patella  and 
its  insertion  while  the  patient  crosses  the  leg  loosely  over  the 
opposite  knee  or  allows  it  to  hang,  relaxed,  over  the  forearm  of 
the  examiner.  Simultaneous  muscular  effort  on  the  part  of 
the  patient  will  serve  to  increase  the  reflex.  The  knee-jerk  is 
increased  in  lateral  sclerosis,  disseminated  sclerosis,  incomplete 
lesions  of  the  cord  above  the  lumbar  segment,  irritability  of  the 
spinal  cord  such  as  occurs  in  spinal  meningitis,  strychnin  poison- 
ing, hysteria,  etc.,  and  in  some  cases  of  organic  cerebral  disease. 
Ix  is  diminished  or  absent  in  locomotor  ataxia,  neuritis,  pseudo- 


572  GENERAL   SYMPTOMATOLOGY. 

muscular  hypertrophy,  poliomyelitis,  myelitis,  and  in  poisoning 
by  spinal  depressant  drugs.  Pronounced  physical  exhaustion 
also  serves  to  lessen  the  tendon  reflexes. 

Ankle-clonus  is  the  term  applied  to  the  vibratory  movements 
of  the  foot  produced  by  forcible  dorsal  flexion  of  the  foot.  It  is 
seldom  if  ever  obtained  during  health,  being  observed  most 
often  in  lateral  sclerosis  and  hysteria. 

The  Babinski  reflex  is  the  extension  of  the  great  toe  which 
follows  tickling  the  sole  of  the  foot.  Normally  flexion  follows 
such  a  procedure.  The  reflex  occurs  most  often  in  hemiplegia, 
diplegia,  and  diseases  of  the  motor  tract  of  the  cord. 

Other  reflexes  occur  in  connection  with  the  arm,  arm-jerk,  and 
the  jaw,  jaw-jerk,  and  are  obtained  by  striking  their  respective 
muscles  while  in  a  state  of  partial  extension.  The  contraction 
of  the  pupil  on  exposure  to  light,  the  closure  of  the  eyelids  on 
irritation  of  the  cornea  or  conjunctiva,  sneezing  following  irrita- 
tion of  the  nares,  and  other  similar  reflexes  are  entitled  to  men- 
tion in  this  connection. 

Paradoxic  contraction  consists  of  a  tetanic  contraction  of  the 
tibialis  anticus  produced  by  forcibly  flexing  the  foot  on  the  leg . 
The  foot  remains  flexed  for  several  minutes  after  which  it 
slowly  relaxes.  It  was  first  described  by  Westphal,  and  may 
be  observed  in  tabes  dorsalis,  hysteria,  paralysis  agitans,  and 
multiple  sclerosis.  The  phenomenon  may  occasionally  be 
produced  in  the  flexors  of  the  leg  and  forearm. 

Vasomotor  disturbances. — Paralysis  of  the  vasomotor  system 
occurs  as  a  symptom  of  hysteria,  neurasthenia,  and  other  func- 
tional neuroses,  and  follows  injuries  of  the  sympathetic  nerve. 
It  is  manifested  by  abnormal  redness  of  the  skin  with  a  sensa- 
tion of  heat  and  a  rise  in  the  dermal  temperature.  Vasomotor 
spasm  is  indicated  by  pallor  and  coolness  of  the  skin  with  formi- 
cation and  stiffness.  It  is  observed  with  functional  disturbances 
of  the  sympathetic  system  and  may  be  followed  by  trophic 
disturbances  such  as  occur  in  scleroderma  and  symmetric 
gangrene. 

Sensory  Phenomena. — Sensibility  may  be  increased,  hyperes- 
thesia; decreased  or  absent,  anesthesia;  or  perverted,  paresthesia. 


GENERAL    SYMPTOMATOLOGY.  573 

In  hyperesthesia,  the  increase  is  often  so  great  that  even  the 
slightest  irritation  may  produce  pain. 

It  may  be  due  to  inflammation  of  the  nerves  as  in  sciatica 
and  multiple  neuritis  when  it  is  associated  with  tenderness  on 
pressure.  It  is  also  present  in  inflammation  of  the  meninges, 
neurasthenia,  and  hysteria. 

Anesthesia  of  the  skin  may  be  complete  or  partial,  and  results 
from  any  disturbance  in  the  conducting  path  from  the  body  sur- 
face to  the  centers  of  sensation.  As  causes,  may  be  mentioned 
neuritis,  traumatism  of  the  nerve  trunks,  organic  disease  of  the 
sensory  tract  in  the  spinal  cord  or  brain,  hysteria,  reflex  irrita- 
tion, drugs  such  as  morphin,  cocain,  and  other  local  anesthetics, 
and  caustics  such  as  the  mineral  acids,  alkalies,  carbolic  acid,  etc. 

Hemianesthesia  is  the  term  applied  to  loss  of  sensation  on  a 
lateral  half  of  the  body.  It  is  usually  associated  with  hemi- 
plegia on  the  same  side  except  when  due  to  a  unilateral  lesion  of 
the  cord  in  its  upper  segment,  when  the  hemiplegia  is  on  the 
opposite  side.  The  condition  is  due  in  most  cases  to  hemor- 
rhages, tumors,  or  local  softening  of  the  posterior  limb  of  the 
internal  capsule,  the  cms  or  peduncle,  the  pons,  the  medulla,  or 
the  occipital  cortex.  Hysteria  is  responsible  for  a  number  of 
cases  of  hemianesthesia.  These  cases  are  paroxysmal  in  char- 
acter and  unassociated  with  loss  of  motion. 

Monanesthesia  is  used  to  denote  loss  of  sensation  in  a  single 
member.  Inflammation,  injury,  or  other  lesion  of  the  correspond- 
ing sensory  nerve  is  the  most  common  cause,  but  it  may  also 
arise  from  focal  lesions  in  the  occipital  cortex,  and  hysteria. 

Paranesthesia  signifies  absence  of  sensibility  of  the  body  and 
extremities  below  the  waist.  Organic  disease  of  the  spinal  cord 
and  neuritis  of  the  large  sensory  nerve  trunks  of  the  lower 
extremities  are  the  most  common  causes.  Hysteria  and  reflex 
irritation  may,  however,  greatly  influence  its  production. 

Thermoanesthesia  is  a  variety  of  diminished  sensibility  of  the 
skin  in  which  it  is  impossible  to  appreciate  heat  or  cold  by 
tactile  impression.  In  health,  it  is  possible  to  recognize  differ- 
ences of  2°  F,  on  the  back,  and  differences  of  1/2°  to  1°  F.  on  the 
fingers  and  face  at  temperatures  from  80°  to  100°  F.     In  disease, 


574  GENERAL    SYMPTOMATOLOGY. 

the  temperature  sense  may  be  lost  while  other  forra.s  of  irritation 
are  appreciated.  It  may  be  observed  in  syringomyelia  and 
hysteria. 

Analgesia  is  that  condition  in  which  there  is  insensibility  to 
pain  as  produced  by  pinching  a  fold  of  skin  pricking  with  a 
needle,  or  by  electric  currents.  Tactile  insensibility  does  not 
necessarily  imply  analgesia.  Loss  of  sensibility  to  pain  is  a 
prominent  feature  of  syringomyelia,  but  may  also  be  observed 
in  peripheral  and  central  nervous  disease  and  in  hysteria. 
>  Delayed  conduction  of  sensory  impulses  is  frequently  observed 
in  anesthesia  from  various  causes.  In  locomotor  ataxia,  it  is 
particularly  common. 

After-sensations  are  the  painful  sensations  which  succeed  mo- 
mentary impressions  such  as  follow  the  prick  of  a  pin.  Some- 
times an  isolated  prick  of  a  pin  is  not  appreciated,  requiring 
repetition  of  the  procedure  several  times,  after  which,  with  a 
varying  interval,  the  painful  sensations  present  themselves. 
This  phenomenon  is  especially  frequent  in  locomotor  ataxia 
and  other  diseases  of  the  cord  and  of  the  nerves. 

Muscular  sense,  or  sense  of  position  is  the  sense  by  which  we  are 
conscious  of  the  position  of  our  limbs,  or  any  movement  of  them. 

Paresthesia  is  applied  to  abnormal  sensations  in  the  skin  such 
as  numbness,  tingling,  itching,  pricking,  formications,  etc.  It 
is  observed  in  numerous  conditions  of  the  nervous  system 
especially  neurasthenia,  hysteria,  spinal  sclerosis,  and  dis- 
turbances of  the  peripheral  nerves.  The  girdle  sensations  which 
occur  in  locomotor  ataxia  and  other  forms  of  spinal  sclerosis 
belong  to  this  class  of  sensory  phenomena. 

Neuralgia  is  the  term  applied  to  paroxysmal  pain  occurring 
along  the  line  of  the  nerve-trunks.  Pressure  usually  serves  to 
relieve  it.  Points  of  tenderness  may,  however,  be  elicited  where 
the  affected  nerve  emerges  from  a  bony  canal  or  from  beneath 
muscular  coverings.  The  lightning-pains  observed  in  locomotor 
ataxia  are  sharp,  lancinating,  neuralgic  pains  occurring  usually 
in  the  extremities.  Causalgia  is  an  intense  burning  neuralgia 
and  is  encountered  most  frequently  in  the  condition  known  as 
"glossy  skin." 


GENERAL   SYMPTOMATOLOGY.  575 

Nutritive  Disturbances.— .4 /'ro^/zy  of  the  muscles  may  result 
from  acute  or  chronic  anterior  poliomyelitis,  inflammation  or 
injury  of  the  nerves,  idiopathic  muscular  disease,  or  disease  such 
as  follows  cerebral  palsies  and  joint  affections. 

Degeneration  oj  the  muscles  may  be  determined  by  their  reac- 
tion to  the  galvanic  electric  current.  In  the  normal  muscle  the 
cathodal  closing  contraction  is  greater  than  the  anodal  closing 
contraction,  and  cathodal  opening  contraction  is  less  than  the 
anodal  opening  contraction.  In  the  early  stages  of  degeneration 
the  anodal  and  cathodal  contractions  are  equal,  both  on  open- 
ing and  on  closing  the  current.  When  the  degeneration  is  ad- 
vanced, cathodal  closing  contraction  is  less  than  anodal  closing 
contraction,  and  cathodal  opening  contraction  is  greater  than 
anodal  opening  contraction.  This,  it  will  be  noticed,  is  a  reversal 
of  the  reaction  of  normal  muscle.  These  degenerative  reactions, 
indicate  suspension  of  trophic  influences  and  are  symptomatic 
of  acute  and  chronic  anterior  poliomyelitis,  acute  central  my- 
elitis, and  inflammation,  traumatism,  or  other  disturbance  of 
the  nerves  which  arrests  their  functions. 

Arthropathies  may  occur  in  certain  organic  diseases  of  the 
nervous  system  such  as  syringomyelia  and  locomotor  ataxia, 
and  consist  of  swelling,  effusion,  and  degenerative  changes  in 
the  joints. 

Ulceration  may  result  in  the  course  of  certain  diseases  of  the 
nervous  system  from  coincident  disturbance  of  nutrition. 
When  ulceration  occurs  on  parts  subjected  to  pressure,  within 
a  few  days,  the  term  acute  decubitus  may  be  employed  to  express 
the  condition;  when  ulcerative  lesions  appear  after  a  long  lapse 
of  time  in  chronic  nervous  diseases,  the  term  chronic  decubitus 
is  applied.  Perforating  ulcer  of  the  foot  such  as  occurs  in  loco- 
motor ataxia  may  also  be  mentioned  in  this  connection.  Some- 
what allied  to  ulceration  due  to  nutritive  disturbances  is  spon- 
taneous gangrene  {Raynaud's  disease)  which  involves  the  fingers, 
toes,  ears,  nose,  etc.,  in  the  absence  of  any  local  causes. 

Trophic  disturbances  involving  the  skin  and  its  appendages 
include  scleroderma,  chloasma,  vitiligo,  atrophia  unguis,  plica, 
trichorrhexis  nodosa,  etc. 


576  GENERAL    SYMPTOMATOLOGY. 

Alterations  in  Breathing. — Cheyne-Stokes  respiration  is  a  condi- 
tion in  which  the  respirations  gradually  increase  in  volume  and 
rapidity  until  they  reach  a  climax,  when  they  gradually  subside, 
and  finally  cease  for  from  ten  to  forty  seconds,  when  the  same 
cycle  begins  again.  It  may  occur  in  tubercular  meningitis, 
cerebral  hemorrhage,  embolism,  thrombosis,  aneurysm  of 
basilar  artery,  uremia,  heart  disease,  etc. 

Disturbances  of  Consciousness. — The  principal  alterations  to 
which  consciousness  is  subject  in  nervous  diseases  are  coma, 
trance,  somnambulism,  ecstasy,  and  catalepsy. 

Coma  is  an  abnormally  deep  and  prolonged  sleep  in  which  the 
cerebral  functions  are  in  abeyance,  characterized  by  stertorous 
breathing,  relaxation  of  the  sphincters,  lividity  of  the  face,  loss 
of  parallelism  of  the  optic  axes,  and  an  inability  to  respond  to 
external  stimuli.  It  may  be  gradual  or  sudden  in  its  onset; 
complete  or  partial,  transient  or  permanent.  It  may  be  due 
to  organic  brain  disease,  traumatism,  cerebral  anemia,  epilepsy, 
sunstroke,  hysteria,  various  convulsive  states,  and  various 
toxic  agents  in  the  blood,  introduced  either  from  without  or 
produced  within  the  body. 

Trance  is  an  hysteric  manifestation  characterized  by  a  pro- 
longed abnormal  sleep  from  which  the  patient  cannot  be  aroused 
and  in  which  the  vital  functions  are  reduced  to  a  minimum. 

Somnambulism  is  a  condition  of  half-sleep  in  which  the  senses 
are  but  partially  suspended  and  the  patient  is  able  to  perform 
various  feats  automatically.  Ordinary  sleep-walking  may 
occur  in  health  but  the  more  pronounced  varieties  of  this  condi- 
tion  are    observed    in   hysteria   and    in    hypnotized    subjects, 

Ecstasy  is  a  peculiar  state  of  the  mind  in  which  a  delusion  so 
governs  the  mental  functions  that  the  entire  nervous  system  is 
held  in  a  condition  of  subjection  or  apparent  insensibility.  It 
is  usually  an  hysteric  manifestation. 

Catalepsy  is  characterized  by  loss  of  will  and  by  muscular 
rigidity.  It  occurs  in  paroxysms  with  loss  of  consciousness,  the 
limbs  remaining  for  long  periods  in  any  position  in  which  they 
are  placed.  It  occurs  in  hysteria,  various  psychoses,  hypnotic 
states,  and  organic  brain  disease. 


GENERAL    SYMPTOMATOLOGY.  577 

Disturbances  of  the  Special  Senses. — The  eye  frequently 
shows  manifestations  of  general  nervous  diseases  that  are  to 
some  extent  characteristic.  Myosis  or  contraction  of  the  pupil 
occurs  in  paresis,  locomotor  ataxia,  meningitis,  brain  tumor, 
disseminated  sclerosis,  uremia,  and  other  similar  conditions; 
while  fnydriasis  or  dilatation  of  the  pupil  may  be  observed  in 
optic  atrophy,  paralysis  of  the  third  nerve,  epileptic  and  hys- 
teric attacks,  paresis,  locomotor  ataxia,  etc.  Unequal  pupils 
may  be  seen  in  health  and  in  local  ocular  disease  in  addition  to 
paretic  dementia,  locomotor  ataxia,  and  affections  interfering 
with  the  nerve-supply  of  the  iris. 

The  Argyll-Robertson  pupil  is  that  which  fails  to  respond  to 
light  but  accommodates  for  distance.  It  is  symptomatic  of 
paresis  and  locomotor  ataxia. 

Conjugate  deviation  of  the  eyes  consists  in  outward  rotation 
of  the  eyes,  such  as  occurs  in  apoplexy  and  cerebral  convulsions 
of  organic  origin. 

Nystagmvis,  or  tremor  of  the  eyeball,  when  unassociated  with 
local  ocular  disease  may  be  taken  as  an  indication  of  dissem- 
inated sclerosis,  Friedreich's  ataxia,  or  affections  of  the  basal 
ganglia. 

Optic  neuritis,  papillitis,  or  choked  disk,  occurs  in  the  course 
of  tumors  and  cerebral  meningitis.  It  may  also  be  produced 
by  Bright's  disease,  syphilis,  anemia,  and  various  toxic  condi- 
tions. 

Primary  optic  atrophy  is  especially  significant  of  locomotor 
ataxia  and  paresis.  Secondary  optic  atrophy  is  usually  due  to 
inflammation,  injury,  tumor,  etc.,  of  the  optic  nerve. 

The  ear  is  also  affected  in  the  discharge  of  its  function  in 
certain  nervous  diseases  but  to  a  less  extent.  Deafness  may  be 
due  to  affections  of  the  auditory  nerve  in  some  part  of  its  course 
but  is  usually  secondary  to  some  local  condition.  Exaggeration 
of  the  hearing  occurs  in  cerebral  hyperemia  and  hysteria.  Tin- 
nitus aurium,  or  ringing  in  the  ears,  arises  from  local  ear  disease, 
cerebral  hyperemia  and  anemia,  and  Meniere's  disease,  and  after 
the  use  of  certain  drugs,  such  as  quinin  and  its  derivative  and 
the  salicylates  in  excess. 
37 


578  DISEASES    OF    THE   CEREBRAL   MEMBRANES. 

Diseases  of  the  Nervous  System  may  be  conveniently  studied 
under  the  following  headings : 

I.  Diseases  of  the  Cerebral  Membranes.  11.  Diseases  of  the 
Cerebrum.  III.  Diseases  of  the  Spinal  Cord.  IV.  Diseases 
of  the  Nerves.     V.   General  Nervous  Diseases. 


DISEASES  OF  THE  CEREBRAL  MEMBRANES. 

Clinically,  the  brain  is  invested  with  only  two  membranes: 
(i)  dura  mater,  and  (2)  the  pia  mater,  or  pia-arachnoid. 

The  dura  lines  the  interior  of  the  skull,  and,  in  addition,  sup- 
ports and  protects  the  brain.  The  falx  cerebri  is  an  extended 
process  of  the  dura  which  extends  into  the  longitudinal  fissure 
and  separates  the  two  cerebral  hemispheres;  the  tentorium  is 
a  process  of  the  dura  separating  the  cerebrum  and  the  cere- 
bellum; th.Q  falx  cerehelli  is  a  process  of  the  dura  extending  be- 
tween the  two  hemispheres  of  the  cerebellum. 

The  blood  supply  for  the  dura  is  from  the  anterior,  middle, 
and  posterior  meningeal  arteries.  The  middle  meningeal  or 
medidural  artery,  a  branch  of  the  internal  maxillary,  is  the 
largest  of  the  three,  and  is  the  vessel  usually  involved  in  menin- 
geal hemorrhage. 

The  nerve  supply  (a  mooted  question)  is  undoubtedly  received 
from  the  fifth  or  trigeminus  pair  of  cranial  nerves,  irritation  of 
which  nerve-supply  may  produce  hyperesthesia,  pain,  reflex 
motor,  and  vaso-motor  disturbances  (Duret).  The  pia  (which 
includes  the  arachnoid,  after  the  suggestion  of  Tuke,  and  which 
Mills  calls  the  arachnopia,  or  pia-arachnoid)  is  composed  of  two 
layers — the  visceral  layer  and  the  parietal  layer.  This  mem- 
brane is  a  vascular  network  held  by  connective  tissue.  The 
visceral  layer  of  the  pia  (formerly  known  as  the  pia  alone) 
closely  invests  the  brain  everywhere,  dipping  into  the  fissures 
and  into  the  ventricles.  The  parietal  layer  (formerly  known 
as  the   arachnoid)    closely    covers   the   dura    in   all   its   parts. 

The  pia-arachnoid  is  the  nutritive  covering  of  the  brain,  sup- 
plying a  considerable  section  with  blood.     The  vessels  of  the  pia 


I'ACHYMENINGITIS.  579 

lie  on  the  surface  and  are  encased  in  perivascular  sheaths  com- 
posed of  the  denser  portions  of  the  membrane.  These  perivas- 
cular spaces  are  the  lymph-canals  accompanying  the  blood- 
vessels into  the  brain-substance  and  communicating  with  the 
subarachnoid  spaces  or  cisterns. 

The  nerve-supply  of  the  pia-arachnoid  is  still  in  dispute,  the 
membrane  being  generally  considered  without  sensation.  This 
is  probably  an  error. 

The  Pacchionian  granulations  are  always  present  in  abun- 
dance "  on  the  outside  of  the  dura,  on  its  inner  surface,  on  the 
arachno-pia,  and  within  the  superior  longitudinal  sinus  and 
the  parasinoidal  spaces.  They  often  indent  the  calvarium,  and 
in  rare  instances  they  penetrate  it.  It  is  generally  conceded 
that  they  are  enlargements  of  the  normal  villi  or  tuft -like  eleva- 
tions of  the  parietal  layer  of  the  pia  (arachnoid).  Repeated 
attacks  of  meningeal  hyperemia  probably  assist  in  their  develop- 
ment."     (Mills.) 

The  term  pachymeningitis  means  inflammation  of  the  dura 
mater;  leptomeningitis  is  inflammation  of  the  pia  and  arachnoid; 
when  the  word  meningitis  is  used  alone,  leptomeningitis  is 
usually  meant. 

PACHYMENINGITIS. 

Synonyms. — Meningitis;  inflammation  of  the  dura  mater. 

Definition. — Inflammation  of  the  dura  mater;  when  the  ex- 
ternal layer  is  primarily  involved,  it  is  termed  pachymeningitis 
externa;  when  the  internal  layer  is  primarily  involved,  it  is 
termed  pachymeningitis  interna. 

Causes. — Pachymeningitis  externa  is  a  surgical  malady,  result- 
ing from  fractures,  penetrating  wounds,  and  other  injuries  of 
the  skull.. 

Pachymeningitis  interna  may  be  due  to  blows  upon  the  head 
without  injury  to  the  skull,  chronic  alcoholism,  scurvy,  Bright's 
disease,  tuberculosis,  and  syphilis.  Chronic  internal  otitis  and 
suppurative  inflammation  of  the  orbit  may  cause  it,  as  may  also 
inflammation  in  the  venous  sinuses  the  result  of  a  thrombus  un- 


580  PACHYMENINGITIS. 

dergoing  suppurative  changes.  Erysipelas,  sun-stroke,  and 
gout  are  recorded  causes. 

Pathologic  Anatomy. — Pachymeningitis  interna  begins  with 
hyperemia  of  the  membrane,  followed  by  an  exudation  which 
develops  into  a  membranous  new  formation,  containing  a  great 
number  of  vessels  of  considerable  size,  but  having  very  thin 
walls.  Hemorrhages  from  these  new  vessels  are  of  frequent 
occurrence,  which  increase  the  size  and  thickness  of  the  neo- 
membrane. 

The  usual  position  of  the  neo-membrane  or  new  formation  is 
on  the  upper  surface  of  the  hemispheres,  extending  downward 
toward  the  occipital  lobe.  The  changes  in  the  adjacent  portion 
of  the  brain  are  dependent  on  the  size  and  thickness  of  the  neo- 
membrane.  Bartholow  observed  a  case  in  which  the  "cyst" 
was  1/2  inch  in  thickness  at  its  thickest  part,  and  it  depressed 
the  hemisphere  correspondingly,  the  convolutions  being  flattened, 
the  sulci  almost  obliterated,  and  the  ventricle  lessened  one- 
half  in  size. 

In  pachymeningitis  syphilitica,  the  pathologic  lesion  is  in  the 
form  of  gummatous  tumors  or  masses  which  may  degenerate  and 
become  either  cheesy  masses  or  be  converted  into  a  purulent- 
looking  fluid. 

In  old  age  the  dura  mater  becomes  thick,  cartilaginous,  and 
of  a  dull  white  color.  The  sheaths  of  the  arteries  are  also 
thickened. 

Symptoms.— These  are  very  obscure  and  are  principally  those 
of  cerebral  compression.  Persistent  headache,  vertigo,  photo- 
phobia, insomnia,  and  gradual  impairment  of  intellect  and  loco- 
motion followed  by  delirium,  convulsions,  and  coma,  or  by 
apoplectic  attacks  and  paralysis,  occurring  in  the  aged  or  those 
in  whom  any  of  the  already-mentioned  causes  exist,  should  lead 
the  examiner  to  suspect  inflammation  of  the  dura  mater.  Epi- 
leptic attacks  sometimes  occur  in  this  condition.  Circum- 
scribed painful  edema  behind  the  ear  and  less  fullness  of  the 
corresponding  side  are  indicative  of  thrombosis  of  the  transverse 
sinus,  a  condition  nearly  always  accompanied  by  pachymenin- 
gitis. 


ACUTE    LEPTOMENINGITIS.  58 1 

Diagnosis. — The  diagnosis  is  always  difficult  and  frequently 
impossible  on  account  of  the  obscurity  of  the  symptoms.  Many 
cases  are  recognized  only  at  autopsy. 

Prognosis. — The  outlook  is  unfavorable  in  all  forms  In  trau- 
matic cases,  surgical  intervention  offers  some  hope  of  cure. 

Treatment. — Pachymeningitis  externa  is  to  be  treated  surg- 
ically. Trephining  is  indicated  in  some  cases.  It  is  claimed 
that  benefit  has  followed  a  thorough  course  of  potassium  iodid. 
In  the  great  majority  of  cases,  however,  all  that  can  be  done  is  to 
treat  symptoms  as  they  arise. 


ACUTE  LEPTOMENINGITIS. 

Synonyms. — Acute  meningitis;  cerebral  fever;  arachnitis. 

Definition. — An  acute  exudative  inflammation  of  the  cerebral 
pia  mater  and  arachnoid  membranes  (pia  arachnoid,  or  arach- 
nopia) ,  usually  limited  to  the  convexity  of  the  cerebrum ;  charac- 
terized by  fever,  vomiting,  headache,  and  delirium,  followed  by 
symptoms  of  general  collapse. 

Causes. — It  may  occur  during  the  course  of  the  infectious 
fevers,  especially  erysipelas,  typhoid  fever,  influenza,  pneu- 
monia, and  diphtheria,  or  it  may  follow  middle-ear  disease  and 
injury  or  disease  of  the  cranial  bones.  It  may  be  secondary  to 
some  tuberculous  focus  elsewhere  in  the  body  or  to  disease  of 
other  serous  membranes.  Among  other  causes  may  be  men- 
tioned cerebral  overwork,  prolonged  wakefulness,  acute  alco- 
holism, exposure  to  the  sun,  and  syphilis.  In  rare  instances 
the  disease  may  occur  as  an  independent  affection.  The  condi- 
tion occurs  most  frequently  in  children  and  young  adults, 
affecting  males  more  often  than  females. 

The  exciting  cause  is  a  microorganism.  In  the  primary 
variety,  the  diplococcus  intracellularis  is  the  exciting  cause;  in 
the  secondary  forms,  the  microorganism  with  which  the  under- 
lying cause  is  associated,  especially  the  pneumococcus,  strepto- 
coccus, typhoid  bacillus,  tubercle  bacillus,  and  the  diphtheria 
bacillus. 


582  ACUTE   LEPTOMENINGITIS. 

Pathologic  Anatomy. — The  inflammatory  changes  may  be  lim- 
ited to  the  convexity  or  to  the  base  of  the  brain  but  more  fre- 
quently both  portions  are  involved.  The  earliest  change  is  hy- 
peremia which  is  soon  followed  by  turbidity  and  opacity  of 
the  affected  membrane.  As  the  process  advances  a  seropuru- 
lent,  purulent,  or  fibrinous  exudate  is  formed  which  distends  the 
subarachnoid  space  and  may  fill  the  ventricles  thereby  com- 
pressing and  flattening  the  convolutions.  The  condition  may 
extend  to  the  brain  substance.  When  due  to  some  general  infec- 
tion the  inflammation  is  more  or  .less  diffused  over  the  entire 
brain,  but  when  secondary  to  some  local  infection  as  middle-ear 
disease  and  tuberculosis,  it  is  basilar  and  to  some  extent  cir- 
cumscribed. The  tubercular  form  is  characterized  by  the  for- 
mation of  small  tubercles  and  a  yellowish  gelatinous  material. 
When  the  ventricular  effusion  is  very  great  it  constitutes  acute 
hydrocephalus . 

Symptoms. — The  onset  may  be  sudden  but  is  usually  gradual 
accompanied  by  such  prodromes  as  persistent  headache,  vertigo, 
irritability  of  temper,  vomiting  without  nausea,  feverishness, 
coated  tongue,  and  constipation.  These  symptoms  may  con- 
tinue from  a  few  hours  to  two  or  three  days. 

The  stage  of  invasion  is  manifested  by  chill,  high  fever,  103°  to 
104°  F.,  rapid  pulse,  100  to  120,  flushed  face,  congested  eyes, 
intense  continuous  headache,  ringing  in  the  ears,  photophobia, 
vertigo,  nausea,  aggravated  vomiting,  delirium,  and  general 
cutaneous  hyperesthesia. 

The  stage  of  excitation  is  characterized  by  increased  cutaneous 
sensibility,  increased  sensitiveness  to  light  and  sound,  furious 
delirium  often  resembling  mania,  continual  jerking  of  the  limbs, 
oscillation  of  the  eyeballs  (nystagmus),  twitching  of  the  facial 
and  other  muscles,  retraction  of  the  head,  arching  backward  of 
the  body,  and  sometimes  convulsions.  The  pulse  is  slow  and 
irregiilar,  and  the  fever  is  high.  Headache  continues  and  may 
be  subject  to  exacerbations  during  which  the  patient  cries  out 
in  a  peculiar  manner  {the  hydrocephalic  cry).  Coated  tongue, 
constipation,  and  retraction  of  the  abdomen  are  present.  The 
finger  drawn  across  the  abdomen  leaves  a  red  line,  the  tache 


ACUTE    LEPTOMENINGITIS.  583 

cerebrate.  The  duration  of  this  stage  is  from  one  day  to  one 
or  two  weeks. 

The  stage  of  depression  or  collapse  appears  as  the  exudate 
accumulates  in  sufficient  quantities  to  induce  marked  pressure 
and  is  manifested  largely  by  paralytic  phenomena.  The  patient 
gradually  becomes  more  quiet,  the  muscular  agitation  and  de- 
lirium subsiding.  Somnolence  develops  and  passes  into  coma; 
at  times  there  is  temporary  consciousness  soon  followed  by 
coma.  The  pulse  is  slow  and  irregular  and  the  fever  is  lessened. 
Various  palsies  such  as  strabismus,  ptosis,  paralysis  of  pupillary 
reaction,  and  relaxation  of  the  sphincters  are  present.  Cuta- 
neous anesthesia,  blindness,  deafness,  and  Cheyne-Stokes 
breathing  eventually  supervene.  Death  ultimately  follows, 
being  ushered  in  with  convulsions  or  coma  with  cyanosis. 

Diagnosis. — The  characteristic  symptoms  of  acute  leptomen- 
ingitis are  rapidly  developed  headache,  vomiting  unassociated 
with  nausea  or  gastric  trouble,  fever,  and  delirium. 

Cerebrospinal  meningitis  may  be  distinguished  by  the  marked 
spinal  symptoms,  the  eruption,  the  presence  of  the  diplococcus 
intracellularis  in  the  fluid  withdrawn  by  lumbar  puncttu-e,  and 
its  occurrence  in  epidemics. 

Tubercular  meningitis  is  attended  by  symptoms  referable  to 
disease  at  the  base  of  the  brain  and  by  the  symptoms  of  tuber- 
culosis elsewhere  in  the  body.     Its  onset  is  slow  (and  see  page 

587). 

Cerebral  complications  in  typhoid  fever,  typhus  fever,  rheum,a- 
tism,  pneumonia,  etc.,  may  be  confused  with  acute  leptomenin- 
gitis, but  a  careful  study  of  the  history,  symptoms,  etc.,  will 
serve  to  make  a  distinction. 

Uremia  differs  from  acute  leptomeningitis  in  that  the  face  is 
turgid  and  edematous,  the  eyelids  are  puffy,  albuminuria  is  con- 
stant, an  irregular  temperature  is  present,  and  convulsions  are 
common,  while  in  leptomeningitis  the  face  is  pale,  edema  is 
absent,  albuminuria  seldom  occurs,  and  the  attack  begins  with 
chills  followed  by  fever. 

Delirium  tremens  is  characterized  by  busy  delirium,  the  patient 
imagining  that  he  is  surrounded  with  persons  and  animals  and 


584  ACUTE   LEPTOMENINGITIS. 

is  wild  in  his  gestures  and  utterances ;  the  temperature  is  normal 
or  subnormal  and  the  skin  is  wet  and  clammy.  In  leptomen- 
ingitis the  delirium  is  mild  but  incoherent,  the  surface  is  hot 
and  dry  and  there  is  severe  vomiting  and  headache. 

Prognosis. — The  outlook  is  very  unfavorable.  If  recognized 
early  and  treated,  a  fair  number  of  recoveries  occur,  but  it 
usually  leaves  the  patient  subject  to  attacks  of  epilepsy  or  with 
a  persistent  headache,  and  more  or  less  mental  impairment. 
Blindness  and  chronic  internal  hydrocephalus  are  rare  results. 
The  duration  is  from  a  few  days  to  two  or  more  weeks. 

Treatment. — Keeping  in  view  the  course  and  general  progno- 
sis of  leptomeningitis,  it  is  questionable  if  any  very  active  medica- 
tion will  abate  the  disease  during  any  stage.  Absolute  rest 
in  a  quiet,  well  ventilated  room  with  the  head  elevated  will, 
however,  serve  to  lessen  the  severity  of  the  symptoms.  The 
diet  should  be  liquid  in  character;  all  the  secretions  should 
receive  attention;  and  an  ice-bag  should  be  applied  to  the  head 
to  relieve  the  intense  headache.  In  vigorous  or  sthenic  cases, 
with  high  febrile  reaction  and  exaggeration  of  the  early  symp- 
toms, venesection  or  leeches  behind  the  ears,  to  the  temples,  or 
in  the  nuchal  region  may  be  employed,  followed  by  the  applica- 
tion of  cold  and  the  internal  administration  of  fluidextract  of 
ergot  in  large  doses  every  two  hours.  The  cerebral  circulation 
may  be  markedly  influenced  by  compression  of  the  carotids. 
Vomiting  may  be  satisfactorily  relieved  in  nearly  all  cases  by 
the  use  of  hydrated  chloral,  gr.  iii  to  v  (0.2  to  0.3  gm.),  diluted, 
every  half-hour  by  the  mouth  until  relieved,  or  in  doses  of  from 
gr.  X  to  XV  (0.6  to  I  gm.)  by  the  rectum.  The  restlessness, 
convulsions,  delirium,  etc.,  require  the  use  of  morphin,  bromids, 
chloral,  phenacetin,  and  similar  drugs.  Temperature  may 
be  reduced  by  hydrotherapy.  The  course  of  the  disease  may 
be  greatly  influenced  by  lumbar  puncture.  The  various  prep- 
arations of  mercury  are  often  of  great  value,  particularly  in 
chronic  cases.  In  the  late  stages,  tonics  and  stimulants  should 
be  freely  given  combined  with  the  use  of  potassium  iodid  and 
iodid  of  iron,  and  the  application  of  flying  blisters. 


TUBERCULAR    MENINGITIS.  585 

TUBERCULAR  MENINGITIS. 

Synonyms. —  Basilar  meningitis;  acute  hydrocephalus. 

Definition. — An  inflammation  of  the  leptomeninges  (pia- 
arachnoid),  particularly  the  basal  pia-mater,  attended  with  or  due 
to  the  deposit  of  gray  miliary  tubercle,  characterized  by  gradual 
decline  of  the  bodily  and  mental  powers  in  addition  to  symp- 
toms referable  to  meningeal  inflammation. 

Causes.— It  usually  occurs  as  a  secondary  affection;  commonly 
a  sequel  to  tubercular  disease  of  some  other  organ.  It  is  ob- 
served most  frequently  in  children  between  two  and  six  years  of 
age,  although  numerous  cases  are  reported  as  having  occurred 
between  the  ages  of  twenty  and  thirty  years.  The  influence 
of  the  scrofulous  diathesis,  so-called,  in  the  production  of  this 
affection  is  very  great.  The  "  gelatinous  children  of  albuminous 
parents,"  as  the  phrase  goes,  possess  a  special  susceptibility 
for  tubercular  meningitis. 

Pathologic  Anatomy. — The  deposition  of  tubercle  usually  oc- 
curs at  the  base  of  the  brain.  Depositions  of  grayish  white 
granules  of  a  translucent,  somewhat  gelatinous  appearance — mil- 
iary tubercle — are  distributed  along  the  vessels  of  the  pia  mater, 
resulting  in  inflammation  and  the  exudation  of  lymph,  with 
the  consequent  thickening  and  opacity  of .  the  membranes. 
The  cerebral  tissue  is  not  usually  involved,  although  on  section 
the  lines  indicative  of  blood-vessels  are  very  much  increased  in 
number.  The  ventricles  are  distended  by  a  clear,  or  milky, 
or  even  bloody  serum.  The  presence  of  the  tubercles  alone 
may  give  rise  to  no  symptoms  until  the  exudative  products  of 
the  resultant  inflammation  develop. 

Tubercular  deposits  occur  also  in  the  lungs,  intestines,  and  at 
times,  in  other  organs. 

Symptoms. — The  onset  may  be  sudden  or  gradual.  Con- 
vulsions may  usher  in  the  attack.  Prodromal  symptoms  are 
usually  present.  The  child  becomes  irritable  and  there  are 
present  anorexia,  loss  of  flesh,  swelling  of  the  abdomen,  con- 
stipation alternating  with  diarrhea,  irregular  periods  of  fever 
with  grinding  of  the  teeth,   and  sleeplessness.     Headache  oc- 


586  TUBERCULAR    MENINGITIS. 

curs  as  is  shown  by  the  child,  even  when  at  play,  stopping  and 
resting  its  head  on  its  hand  or  on  the  floor.  The  duration  of 
this  stage  is  from  one  week  to  one  or  two  months. 

The  stage  of  excitation  begins  suddenly  with  obstinate  vomit- 
ing, severe  headache,  convulsions,  fever,  102°  to  103°  F.,  in  the 
evening;  falling  to  99°  F.,  in  the  morning,  and  a  soft  and  com- 
pressible, irregular  pulse.  On  drawing  the  finger  nail  lightly 
over  the  surface  of  the  body  a  red  line  results,  "  the  cerebral 
stain,"  of  Trousseau.  The  special  and  general  senses  become 
exalted,  resulting  in  photophobia,  tinnitus  aurium,  intolerance 
to  sound,  and  cutaneous  hyperesthesia.  The  muscles  are  sub- 
ject to  spasmodic  contraction  and  rigidity,  at  times  giving  rise 
to  opisthotonos.  This  period  of  the  disease  lasts  from  two 
weeks  to  a  month. 

The  stage  of  depression  follows  the  preceding  and  is  the  result 
of  the  pressure  of  the  exudation  on  the  brain.  The  pulse  is 
slow  and  compressible  and  its  rhythm  irregular.  The  tempera- 
ture becomes  less.  A  tendency  to  somnolence  alternating  with 
quiet  delirium  soon  becomes  manifest.  There  are  also  contin- 
ual movements  of  the  fingers,  as  in  picking  up  objects,  mental 
stupor,  periodic  convulsions,  strabismus,  and  oscillation  of  the 
eyeballs.  Intervals  of  wakefulness  occur  during  which  the  head- 
ache becomes  excruciating,  causing  the  peculiar  shrill  cry  or 
shriek,  "the  hydrocephalic  cry,"  These  are  associated  with  con- 
traction of  the  facial  muscles  as  if  intense  suffering  were  experi- 
enced. Collapse  finally  occurs  with  Cheyne-Stokes  breathing  and 
deepening  coma  which  eventually  terminates  in  death  with  or 
without  convulsions.  The  duration  of  this  stage  is  from  one  or 
two  days  to  a  week. 

Diagnosis. — Acute  leptomeningitis  and  tubercular  meningitis 
have  closely  analogous  symptoms  during  the  stage  of  excita- 
tion, but  the  history  and  clinical  course  of  the  two  maladies 
determine  the  diagnosis.  The  following  table  (from  Wheeler 
and  Jack)  will  be  of  service: 


DISEASES    OF    THE    CEREBRUM.  587 


Simple  Meningitis.  Tubercular  Meningitis. 


Age. — Any  age Young     children     and     young 

adults. 

Cause. — Injury  or  local  causes,  No  local  cause,  but  symptoms 
fevers,  etc.  of  tubercle  elsewhere. 

Course. — Short Longer  than  simple,  especially 

the   prodromal   stage. 

Convulsions. — May  be  present Common,  even  during  the  com- 
pression stage,  often  precede 
death. 

Abdomen. — Nothing  marked Markedly  retracted. 

Pathology. — i.  That  of  simple  or  That  which  is  associated  with 
suppurative  inflammation.  the    presence  of  tubercle,  and 

formation  of  peculiar  greenish 
pus. 

2.  Attacks  convexity  of  brain.  .  .        2.   Attacks   the  base  of  brain. 

3.  Ventricles  not  distended 3.    Ventricles    are    distended, 

and  may  cause  hydrocephalus. 
Prognosis. — Almost  hopeless Depends  on  cause  and  extent. 

Prognosis. — Unfavorable.  The  usual  duration  is  three  or  four 
weeks  after  fully  developed  prodromes.  If  ushered  in  by  con- 
vulsions, the  duration  is  shorter. 

Treatment. — There  are  no  means  of  retarding  the  disease. 
The  measures  recommended  under  Acute  Leptomeningitis  may 
be  of  service  in  rendering  the  patient  more  comfortable  Cod- 
liver  oil,  syrup  of  the  iodid  of  iron,  syrup  of  hydriodic  acid,  and 
quinin  should  also  be  administered. 

DISEASES  OE  THE  CEREBRUM. 

To  understand  the  symptoms  in  diseases  of  the  nervous  sys- 
tem, a  clear  and  precise  knowledge  of  the  anatomy  and  physiol- 
ogy is  necessary.  Presuming  this  knowledge,  only  a  very  few 
of  the  most  elementary  facts  will  be  mentioned  before  discussing 
diseases  of  the  brain  and  cord. 


588  DISEASES  or  the  cerebrum. 

The  nerve-cell  is  the  real  foundation  of  the  nervous  system.  It 
receives  its  nourishment  from  the  arterioles  and  the  lymphatics, 
and  is  drained  by  the  venules,  as  are  other  tissues,  and  is  sup- 
ported by  the  connective  tissue  known  as  neuroglia.  Each 
nerve-cell  has  two  kinds  of  processes,  the  axis  cylinder  process 
and  the  protoplasmic  process;  the  three — the  cell  and  the  two 
processes — are  known  as  the  neuron,  the  entire  nervous  system 
being  made  up  of  neurons.  The  axis-cylinder  processes  conduct 
the  nerve  impressions  or  current  from  the  cells.  The  proto- 
plasmic process  conducts  the  nervous  current  or  impressions  into 
the  cell,  and  it  is  through  these  processes  and  their  collaterals 
that  the  cell  is  brought  into  communication  with  all  portions 
of  the  body.  The  nerve-cells — "the  very  inner  citadel  of  ner- 
vous life" — are  mainly  set  in  the  gray  matter  of  the  brain  and 
the  spinal  cord,  and  the  axis-cylinder  processes  and  the  pro- 
toplasmic processes  run  in  bundles  or  collections  in  the  white 
matter  of  the  brain  and  spinal  cord.  The  gray  matter  of  the 
brain  and  spinal  cord,  or  the  nerve-cells,  is  found  chiefly  in  the 
cortex  of  the  cerebrum  and  the  basal  ganglia,  in  the  cortex  of 
the  cerebellum,  in  the  horns  of  the  spinal  cord,  and  in  the  nuclei 
of  the  medulla  oblongata,  and  all  these  masses  of  gray  matter 
or  cells  are  connected  by  nerves,  or  white  matter,  each  protected 
by  connective  tissue.  The  cells  endow  the  nerves  with  their 
particular  functions.  A  knowledge  of  the  physiology  of  the 
nervous  system  is  essential  in  order  to  understand  the  alterations 
in  the  functions  of  the  different  masses  of  gray  matter,  or  cells, 
and  of  the  nerves,  or  white  matter. 

A  knowledge  of  the  blood  supply  of  the  brain  is  of  great 
practical  importance,  and  particularly  for  the  understanding  of 
the  symptoms  and  pathology  of  apoplexy  and  cerebral  emboli. 

The  external  carotids  on  each  side  supply  blood  to  the  scalp, 
the  skull,  and  the  dura  mater. 

The  internal  carotid  artery  on  each  side,  and  the  vertebral 
arteries  supply  the  brain,  pia  mater,  and  the  eyes. 

The  internal  carotid  arteries  divide  into  the  anterior  cerebral 
and  the  middle  cerebral  arteries. 

The  vertebral  arteries  on  each  side  give  off  the  inferior  cere- 


DISEASES    OF    THE    CEREBRUM. 


589 


bellar  arteries,  and  then  join  and  form  the  basilar  artery,  which 
divides,  forming  the  two  posterior  cerebral  arteries,  which,  in 
turn,  give  off  a  posterior  communicating  artery.  It  is  the  union 
of  these  cerebral  arteries  by  the  anterior  and  posterior  commu- 
nicating arteries  that  forms  the  circle  of  Willis.  From  various 
portions  of  the  circle  of  Willis  and  the  beginnings  of  the  anterior, 
middle,  and  posterior  cerebral  arteries  are  given  off  six  groups 
of  vessels,  which  furnish  the  blood-supply  to  the  basal  ganglia 
and  the  adjacent  white  matter,  from  which  they  derive  their 


Fig.  58. — Localization  of  function  on  the  cerebral  cortex;  external  surface  (Starr;. 
(From  Woolsey's  Surgical  Anatomy.) 


name,  "the  central  arteries  of  the  brain."  The  "central 
arteries"  given  off  by  the  middle  cerebral  or  Sylvian  artery  are 
of  the  most  importance  to  the  clinician.  They  are  know^n  as 
the  lenticular-optic  and  the  lenticular-striate  arteries,  and  are 
usually  involved  in  cerebral  hemorrhage. 

Without  a  knowledge  of  the  known  centers  of  "localization" 
it  is  impossible  to  interpret  the  symptoms  of  diseases  of  the 
nervous  system. 

The  motor  area  is  entirely  in  front  of  the  fissure  of  Rolando, 


590  DISEASES    OE    THE    CEREBRUM. 

"All  diseases  which  destroy  any  considerable  portion  of  this 
cortical  area  invariably  produce  paralysis  of  the  opposite  half 
of  the  body;  while,  no  matter  how  extensive  the  destructive 
process  elsewhere  in  the  cortex,  motion  remains  intact  if  this 
is  not  touched."  This  region  may  be  further  "localized"  for 
separate  groups  of  muscles. 

The  center  for  muscular  sense  is  believed  to  be  located  largely 
in  the  parietal  lobe. 

The  sensory  areas  are  located  in  the  cortex;  their  exact  situa- 
tion is  not  absolutely  proved,  but  they  are  believed  to  be  pos- 
terior to  the  motor  areas. 

The  auditory  center  is  located  in  the  first  temporal  gyrus. 

The  visual  center  is  in  the  occipital  lobe  and  its  cortical  area 
in  the  cuneus  and  adjacent  convolutions. 

The  speech  center  (Broca's  center)  is  located  in  the  posterior 
part  of  the  third  left  frontal  convolution  (Broca's  convolution) 
in  right-handed  individuals  and  in  the  similar  convolution  on 
the  right  side  in  left-handed  persons.  The  various  phenomena 
resulting  from  injury  or  disease  of  this  area  are  termed  col- 
lectively aphasia.  Tyson  describes  it  as  a  loss  of  power  to 
comprehend  words  correctly  and  to  use  them  properly.  It  may 
be  subdivided  into  mind-blindness,  apraxia,  word-blindness, 
alexia,  loss  of  memory  for  words,  amnesia,  word-deafness,  etc. 

The  "  mind"  center  has  long  been  considered  as  located  in  the 
frontal  lobe,  anterior  to  the  motor  area  and  the  third  frontal  con- 
volution, but  of  late  the  view  is  growing  that  for  complete  integ- 
rity of  the  mind  the  entire  cortex  must  be  intact,  although 
lesions  of  the  portions  named  produce  mental  symptoms  only, 
while  lesions  of  other  portions  of  the  cortex  cause  other  disorders 
in  which  mental  changes  are  more  or  less  prominently  observed. 

The  many  symptoms  resulting  from  diseases  of  the  brain  can 
be  placed  in  four  groups: 

I.  General  symptoms  of  brain  irritation.  2.  General  symp- 
toms of  brain-pressure.  3.  Symptoms  of  focal  irritation  or 
destruction.  4.  Symptoms  due  directly  to  the  pathologic 
process. 

Symptoms  of  brain  irritation,  or  hyperemia,  are:  headache,  ver- 


CONGESTION    OF    THK    BRAIN.  59I 

tigo,  vomiting,  photophobia,  mental  irritability,  insomnia,  full- 
ness or  pressure  over  the  brain,  with  scalp  tenderness  and  noises 
in  the  ears.  Rarely  convulsive  symptoms  and  delirium  may 
occur. 

Symptoms  of  brain-pressure  are :  headache,  vomiting,  mental 
dullness,  and  frequently  some  form  of  paralysis  with  contracted 
pupil  and  finally  coma. 

Focal  symptoms  depend  on  the  character  of  the  lesions;  if 
irritative,  convulsive,  or  spasmodic  phenomena;  if  located  in  the 
motor  area;  and  if  decided  pressure  or  destructive  lesions, 
paralysis,  such  as  hemiplegia,  and  aphasia. 

The  symptoms  of  brain  lesions  due  to  the  pathologic  process, 
itself,  have  few  if  any  particular  symptoms  other  than  those  due 
to  the  location,  except  in  abscess,  when  the  constitutional  symp- 
toms of  suppuration,  such  as  chills,  fever,  sweats,  and  prostra- 
tion, are  added  to  other  brain  symptoms. 

CONGESTION  OF  THE  BRAIN. 

Synonyms. — Cerebral  hyperemia;  cerebral  congestion. 

Definition. — An  abnormal  fiillness  of  the  vessels  (capillaries) 
of  the  brain:  Active,  when  arterial  iullness;  passive,  when  venous 
fullness;  characterized  by  headache,  vertigo,  disorders  of  the 
special  senses,  and,  if  the  hyperemia  be  decided,  convulsions. 

Causes. — Active.  Increased  cardiac  action,  the  resiilt  of 
hypertrophy  of  the  left  ventricle;  general  plethora;  excesses  in 
eating  and  drinking;  acute  alcoholism;  sunstroke;  inhalation  of 
amyl  nitrite;  prolonged  mental  labor;  diminished,  amount  of 
arterial  blood  in  other  parts;  compression  of  the  abdominal 
aorta  or  ligation  of  a  large  artery,  or  the  suppression  of  an 
habitual   bleeding   hemorrhoid,    are   the   principal    causes. 

Passive.  Dilatation  of  the  right  heart;  pressure  upon  the 
veins  returning  the  cerebral  blood;  emphysema;  and  similar 
conditions  interfering  with  the  venous  circulation. 

Pathologic  Anatomy. — The  post-mortem  appearances  are: 
Overloading  of  the  venous  sinuses  and  of  the  meningeal  vessels, 
including  the  finer  branches;  the  pia  mater  appears  vascular 


592  CONGESTION    OF    THE    BRAIN. 

and  opaque ;  the  gray  matter  of  the  convolutions  unduly  red ; 
the  convolutions  may  be  compressed  and  the  ventricles  con- 
tracted with  the  displacement  of  a  corresponding  amount  of 
cerebrospinal  fluid.  Long-continued  or  repeated  congestions 
lead  to  enlargement  and  tortuosity  of  all  the  vessels,  a  moist 
and  slimy  condition  (edema)  of  the  cerebral  substance,  and  an 
increase  in  the  subarachnoid  fluid. 

Symptoms. — "Rush  of  blood  to  t*he  head"  may  be  gradual 
or  sudden  in  its  onset,  the  symptoms  aggravated  by  the  recum- 
bent position.  Headache,  with  paroxysmal  neuralgic  darts, 
disorders  of  vision  and  hearing,  buzzing  in  the  ears  and  sparks 
before  the  eyes,  contracted  pupils,  vertigo,  blunted  intellect, 
inability  to  concentrate  the  mind,  irritable  temper,  and  curious 
hallucinations  are  present.  The  face  is  red,  the  eyes  congested, 
and  the  carotids  pulsating.  The  sleep  is  disturbed  by  dreams 
and  jerkings  of  the  limbs.  If  the  attack  be  sudden  (apoplecti- 
form),  unconsciousness   with   muscular   relaxation   will   occur. 

Cerebral  hyperemia  in  children  often  presents  alarming  symp- 
toms, such  as  great  restlessness,  insomnia,  night-terrors,  gnash- 
ing of  the  teeth  during  sleep,  vomiting,  contraction  of  pupils 
followed  by  general  convulsion,  etc.  Any  or  all  of  these  symp- 
toms may  continue  more  or  less  marked  from  an  hour  or  two 
to  a  day,  the  child  enjoying  its  usual  health,  after  a  sound  sleep, 
save  a  feeling  of  fatigue. 

Prognosis. — Mild  cases  terminate  favorably  in  a  few  hours  to 
a  day  or  two,  but  show  a  strong  tendency  to  recur.  Severe 
cases  (apoplectiform)  may  terminate  in  health,  but  usually 
foretell  cerebral  hemorrhage.  The  passive  form  is  controlled 
by  the  lesions  giving  rise  to  it. 

Treatment. — Active  fonn.  The  cause  should  be  removed  if 
possible.  Elevate  the  head  and  apply  cold,  either  cold  cloths 
or  the  ice-cap;  at  the  same  time  warmth  to  the  feet.  Leeches 
to  the  mastoid,  or  cups  to  the  neck,  or  in  the  apoplectiform 
variety  venesection  should  be  employed,  to  diminish  the  intra- 
cranial blood-pressure;  compression  of  the  carotids,  or  liga- 
tures about  the  thighs,  have  been  recommended. 

Active  purgation  is  indicated  either  by  croton  oil  or  magne- 


CEREBRAL  ANEMIA.  593 

sium  sulphate,  by  the  mouth.     The  following  enema  is  often 
valuable : 

I^.      Magnesii  sulphatis 5ii  60.  gm. 

Glycerini f  5j  30,  c.c. 

Aquas  bul f  5iv  120.  c.c. 

M.  S. — Administer  slowly  per  rectum,  with  little  force. 

In  mild  cases  the  application  of  an  ice-cap  to  the  head,  a  sina- 
pism to  the  nucha,  and  potassium  bromid,  gr.  xxx  to  xl  (2  to  2.6 
gm.),  repeated  and  the  enema  mentioned  above,  control  the 
symptoms.  Fluidextract  of  ergot  is  strongly  recommended, 
but  its  value  seems  to  be  overestimated. 

In  severe  cases  »with  forcible,  overacting  heart,  tincture  of 
aconite  or  veratrum  viride  may  be  used  in  addition  to  the 
measures  already  mentioned. 

Passive  form.  The  treatment  should  be  directed  entirely 
toward  the  condition  producing  the  venous  stasis. 

CEREBRAL  ANEMIA.  * 

Definition.— An  abnormal  decrease  in  the  quantity  of  blood 
in  the  cerebral  vessels;  general,  when  the  diminished  supply  in- 
cludes all  the  vessels;  partial,  when  the  diminished  supply  is 
limited  in  area;  characterized  by  pallor,  headache,  vertigo, 
some  loss  of  power,  and,  rarely,  conviilsions. 

Causes. — Partial  cerebral  anemia  results  from  obstruction  of 
a  vessel,  from  embolism  or  thrombosis.  General  cerebral  anemia 
results  from  hemorrhages,  wasting  diseases,  during  convales- 
cence from  severe  attacks  of  fevers,  sudden  shock,  feeble 
cardiac   action,    valvular   heart    disease,    and   general   anemia. 

Pathologic  Anatomy. — The  functional  ac+ivity  of  the  brain  de- 
pends upon  the  quantity  and  quality  of  the  blood  circulating 
in  the  cerebral  capillaries.  Any  decrease  in  the  normal  quantity 
or  impairment  in  the  quality  produces  the  symptoms  of  cere- 
bral anemia.  The  brain  is  pale  and  milky  in  color,  and  on 
transverse  section  there  are  no  bloody  points ;  the  ventricles  and 
perivascular  lymph-spaces  are  well  filled  with  fluid. 

In  partial  anemia  the  deficiency  in  the  blood-supply  is  local 
corresponding  to  the  area  supplied  by  the  obstructed  vessel. 
38 


594  CEREBRAL  ANEMIA. 

Symptoms. — In  general  cerebral  anemia,  there  are  present 
pallor,  fainting  attacks,  vertigo  worse  on  exertion,  yawning 
tendency,  headache  relieved  by  the  recumbent  posture,  and 
sometimes  convulsions.  In  partial  anemia,  there  is  sudden 
loss  of  power  of  a  limited  muscular  area  which  gradually  returns 
to  normal.  Cerebral  anemia  may  be  acute  or  chronic  according 
as  the  causes  are  sudden  or  gradual  in  character. 

Diagnosis. — Cerebral  hyperemia  is  characterized  by :  Fullness 
in  the  head,  vertigo,  restlessness,  insomnia  or  disturbed  sleep, 
ringing  in  the  ears,  and  f orgetf ulness ;  on  lying  down  the  symp- 
toms become  worse ;  hyperemia  of  the  retina  may  be  detected 
by  the  ophthalmoscope. 

Cerebral  anemia  is  characterized  by:  Pallor,  nausea,  vertigo, 
yawning,  dilated  pupil,  headache,  tinnitus  aurium,  and  forgetful- 
ness ;  on  lying  down  the  symptoms  improve ;  pallor  of  the  retina 
may  be  detected  by  the  ophthalmoscope. 

Prognosis. — The  outlook  is  favorable  in  those  cases  in  which 
the  cause  may  be  removed.  In  cases  resulting  from  severe  and 
repeated  hemorrhages,  the  prognosis  is  unfavorable. 

Treatment. — In  anemia  of  the  brain  due  to  general  anemia, 
regulated  diet  and  the  administration  of  iron,  arsenic,  quinin, 
strychnin,  etc.,  should  be  prescribed.  A  certain  number  of 
hours  daily  in  the  recumbent  posture  is  of  advantage.  When 
there  is  a  decided  tendency  to  attacks  of  swooning,  quickly-act- 
ing diffusible  stimulants  such  as  aromatic  spirits  of  ammonia, 
Hoffman's  anodyne  (spirit  of  nitrous  ether),  nitroglycerin, 
etc.,  should  be  given.  Amyl  nitrite,  cautiously  administered, 
may  be  used  at  times.  The  following  prescription  will  be 
found  of  value  in  improving  the  quantity  and  quality  of  the 
blood  in  these  cases: 

I^.     Strychninae  sulph gr.  j  .065  gm. 

Quininas  sulph gr.  xlviij  3  .  i       gm. 

Acid,  hydrochlorici  dil.  .    f5ij  8.         c.c. 

Tinct.   gentian,   comp  . . .   fBiij  90.         c.c. 

Tinct.  card,  comp.q.s.  ad  f  Bvj        ad  180.          c.c. 

M.  S. — Teaspoonful  in  water,  after  meals. 


CEREBRAL   HEMORRHAGE.  595 

In  those  cases  due  to  heart  disease,  hemorrhages,  etc.,  the 
remedial  measures  advised  for  those  conditions  should  be  in- 
stituted in  addition. 

CEREBRAL  HEMORRHAGE. 

Synonyms. — Apoplexy;  "a  stroke." 

Definition. — The  sudden  rupture  of  a  cerebral  vessel  and 
escape  of  blood  into  the  cerebral  tissue,  causing  pressure  and 
more  or  less  destruction  of  the  brain-substance,  characterized 
by  sudden  unconsciousness,  irregular,  noisy  respiration,  and 
complete  muscular  relaxation. 

Causes. — It  is  a  disease  of  the  aged,  seldom  being  encountered 
in  individuals  under  forty  years  of  age.  Apoplexy  early  in  life 
is  usually  syphilitic.  Under  ordinary  circumstances  it  seems  to 
occur  most  frequently  in  the  spring  and  autumn.  The  principal 
cause  is  disease  of  the  vessels,  manifesting  itself  in  the  develop- 
ment of  miliary  aneurysms  or  in  a  chronic  endarteritis  with  an 
associated  cardiac  hypertrophy.  As  contributory  causes  may 
be  mentioned  heredity,  Bright's  disease,  syphilis,  chronic 
alcoholism,  and  the  various  other  affections  that  induce  arterial 
degeneration.  The  condition  may  be  precipitated  by  emotion, 
overexertion,  acute  indigestion,  acute  alcoholism,  and  similar 
disturbances. 

Pathologic  Anatomy. — The  most  common  locations  of  cere- 
bral hemorrhages  are  the  regions  supplied  by  the  "  central  ar- 
teries," the  internal  capsule,  corpus  striatum,  and  thalamus 
opticus;  less  common,  the  cerebellum;  next  in  frequency,  the 
pons  and  medulla  oblongata,  and  rarely  on  the  convexity  of 
the  brain,  termed  meningeal  hemorrhage. 

Intracerebral  hemorrhage  is  more  common  upon  the  right  than 
upon  the  left  side,  and  especially  affects  the  region  of  the  caudate 
nucleus,  lenticular  nucleus,  internal  capsule,  and  optic  thalamus; 
and  particularly  the  outer  border  of  the  lenticular  body,  which  is 
supplied  by  the  striate  artery,  the  artery  of  cerebral  hemor- 
rhage. These  lenticular  striate  arteries  are  branches  of  the 
Sylvian  artery,  and  have  no  anastomoses.  When  the  hemor- 
hage  is  large,  the  blood  may  break  into  the  ventricles  and  pass 


596  CEREBRAL  HEMORRHAGE. 

by  the  iter  from  the  third  to  the  fourth  ventricle.  A  recent  clot 
is  dark  in  color,  and  in  consistency  a  soft,  grumous  mass,  com- 
posed of  coagulated  blood  and  brain  substance  in  varying  pro- 
portions, at  whose  center  is  the  opening  into  the  ruptured 
vessel.  The  clot  excites  inflammation  around  it,  resulting  in  its 
becoming  encysted,  by  the  development  of  new  connective 
tissue  from  the  neuroglia,  and  then  being  gradually  absorbed, 
leaving  a  cicatrix;  or  the  brain-tissue  around  the  clot  softens 
and  degenerates — localized  softening. 

Symptoms. — The  attack  may  occur  suddenly  as  an  apoplectic 
shock  or  stroke,  or  slowly  with  prodromes  or  "  warnings." 

Prodromes:  Headache,  vertigo,  transient  deafness  or  blind- 
ness, sensation  of  numbness  of  the  extremities,  with  local  palsies, 
together  with  the  constant  dread  of  an  attack. 

The  attack  may  begin  with  vomiting,  followed  by  either 
partial  or  complete  insensibility,  or  suddenly,  the  patient 
becoming  at  once  unconscious  and,  if  standing  at  the  time, 
sinking  to  the  ground  completely  relaxed  or,  rarely,  with  spas- 
modic or  convulsive  movements.  Respiration  is  slow,  irregular, 
and  noisy;  during  inspiration  the  paralyzed  cheek  is  drawn  in; 
and  during  expiration  puffed  out.  The  pulse  is  slow  and  full 
and  there  is  throbbing  of  the  carotids.  The  face  is  flushed, 
the  eyes  congested,  and  the  pupils  are  uninfluenced  by  light. 
The  temperature  falls  a  degree  or  two  below  normal  but  rises 
within  twenty-four  hours  to  100°  to  101°  F.  In  fatal  cases  the 
temperature  may  rapidly  rise  to  106°  to  108°  F. 

The  muscular  system  is  profoundly  relaxed,  and  the  reflex 
movements  are  abolished.  Involuntary  urination  and  defeca- 
tion are  frequent.  The  head  and  eyes  deviate  in  many  cases 
toward  the  affected  side  in  the  brain  or  from  the  paralyzed  side. 
Convulsions  rarely  occur. 

Ingravescent  apoplexy  begins  as  a  mild  stroke  with  a  rapid 
return  to  consciousness  and  power,  except,  perhaps,  of  speech. 
Headache  is  present  with  some  one  or  more  local  symptoms,  and 
in  a  few  hours  to  a  few  days  consciousness  gradually  becomes 
impaired,  the  loss  of  power  again  occurs,  and  the  coma  deepens, 
the  patient  dying  comatose. 


CEREBRAL   HEMORRHAGE.  597 

If  the  uncon.sciousness  continues  longer  than  twenty-four 
hours,  death  is  the  usual  termination,  preceded  by  pale  face, 
irregular  and  rapid  pulse  and  respiration,  and  rise  of  tempera- 
ture. 

Reaction  takes  place  in  many  cases  in  from  one-half  to  three 
hours,  consciousness  gradually  returning  and  reflex  excitability 
slowly  reviving.  It  is  associated  with  headache,  confusion  of 
mind,  and  more  or  less  paralysis  of  motion  and  sensation  on  one 
side  of  the  body  {hemiplegia).  The  electro-excitability  of  the 
paralyzed  parts  is  preserved.  Irritation  of  the  motor  fibers 
shortly  induces  contraction  of  the  affected  muscles  (primary 
rigidity).  Contractions  later  in  the  course  of  the  affection  are  of 
unfavorable  significance  as  they  indicate  degeneration  in  the 
motor  tracts  (secondary  rigidity).  Recovery  from  the  attack 
may  be  delayed  by  inflammatory  symptoms,  the  temperature 
rising  to  101°  to  104°  F.,  and  by  severe  neuralgic  pains  and  the 
muscle  contractions. 

Localization  of  the  lesion  of  a  cerebral  hemorrhage  is  of  great 
practical  importance. 

Capsular  hemorrhage,  or  hemorrhage  into  the  internal  capsule 
at  the  anterior  portion  around  the  genu  (knee) ,  where  the  motor 
fibers  pass  and  converge,  coming  from  the  hemispheres,  is  fre- 
quent, causing  loss  of  consciousness  of  sudden  or  rapid  onset, 
hemiplegia,  involving  face,  arm,  and  leg,  with  motor  aphasia  if 
the  hemiplegia  be  on  the  right  side.  There  is  also  a  unilateral 
loss  of  reflex  action,  conjugate  deviation  of  the  eyes  from  the 
paralyzed  side,  and  unilateral  defective  movement  with  flaccid- 
ity  of  the  limbs. 

Cortical  hem-orrhage  gives  rise  to  localized  unilateral  paralysis 
of  the  face,  the  arm,  or  the  leg,  with  local  convulsions  or  con- 
vulsions that  have  a  local  beginning,  or  profound  uncon- 
sciousness. 

Centrum,  ovale  hemorrhages  resemble  the  cortical  as  regards  the 
local  convulsions. 

Crus-cerebri  hemorrhage  produces  loss  of  consciousness  with 
hemiplegia  involving  the  lower  half  of  the  face  and  the  limbs, 
with  paralysis  of  the  third  nerve  on  the  opposite  side,  or  the 


598  CEREBRAL  HEMORRHAGE. 

side  of  the  lesion.  The  unilateral  third  nerve  symptoms  are 
ptosis,  external  strabismus,  dilatation  of  the  pupil,  and  loss  of 
accommodation  for  near  objects.  The  paralysis  is  termed 
'^crossed''  or  ''alternate''  hemiplegia. 

Pons  hemorrhage  causes  either  general  convulsions  or  irregular 
convulsions  in  the  legs,  bilateral  motor  paralysis,  bilateral  an- 
esthesia, either  contracted  or  dilated  pupils,  embarrassed  respira- 
tion, repeated  vomiting  without  nausea,  and  high  temperature. 
If  the  hemorrhage  is  large,  death  is  sudden  or  within  a  few 
hours,  and  even  if  small,  the  prognosis  is  unfavorable. 

Ventricular  hemorrhages  are  generally  of  the  ingravescent  va- 
riety, and  are  characterized  by  a  second  apoplectic  seizure  soon 
after  the  first,  with  extension  of  the  hemiplegic  symptoms,  or  a 
relaxation  of  the  muscles,  from  one  side  to  both  sides  of  the  body. 

Cerebellar  hemorrhages  vary  so  greatly  in  the  symptoms  that 
a  positive  diagnosis  can  seldom  be  made. 

Meningeal  or  dural  hemorrhage  is  usually  due  to  a  trauma. 
Two  varieties:  I.  Infantile  ^meningeal  hemorrhage,  occurring 
during  labor.  II.  Extradural  hemorrhage,  the  result  of  direct 
injury  to  the  head. 

The  infantile  variety  presents  symptoms  of  irritation  and 
compression  of  the  cortex,  such  as  convulsions,  general  or  uni- 
lateral; rigidity,  opisthotonos,  and  either  hemiplegia  or  di- 
plegia. 

The  extradural  variety  is  almost  always  the  result  of  fracture 
or  trauma  of  the  skull,  resulting  in  an  extravasation  of  blood 
between  the  dura  and  the  skull,  from  the  middle  meningeal  artery ; 
the  hemorrhage  may  be  on  one  or  both  sides.  The  symptoms 
may  develop  at  once  or  after  some  days,  and  are  those  of  pres- 
sure; hemiplegia,  partial  or  complete;  convulsions,  impaired  or 
absent  reflexes,  dilatation  with  loss  of  reaction  of  pupil  of  oppo- 
site side;  and  stupor,  gradually  deepening  into  coma  and  death. 

Sequelse. — Paralysis  of  the  muscles  of  the  face,  tongue,  body, 
and  extremities  of  one  side,  opposite  to  the  location  of  the  hem- 
orrhage, termed  unilateral  paralysis,  or  right  or  left  hemiplegia. 

Paralysis  of  both  sides  of  the  body,  due  to  simultaneous  hem- 
orrhage on  both  sides,  termed  bilateral  hemiplegia,  or  diplegia. 


CEREBRAL   HEMORRHAGE.  599 

Paralysis  of  one  side  of  the  face  and  of  the  extremities  of  the 
opposite  side,  due  to  hemorrhage  into  the  pons  Varolii,  termed 
alternating  or  crossed  paralysis. 

Occasionally  tonic  contractions  occur  in  muscles  long  par- 
alyzed, termed  late  rigidity,  and  constitute  evidence  of  a  second- 
ary degeneration  of  the  nerve  fibers. 

Choreic  movements  in  paralyzed  muscles  are  termed  post- 
hemiplegic chorea,  due,  according  to  Charcot,  to  changes  in  the 
motor  centers. 

The  mental  powers  are  always  more  or  less  permanently  im- 
paired, the  patient  irritable  and  emotional,  with  loss  of  memory 
in  varying  degrees. 

Diagnosis. — The  diagnosis  of  the  apoplectic  seizure  is  often 
one  of  the  most  difHcult  questions  in  medicine,  and  yet  of  the 
greatest  importance,  as  the  treatment  depends  upon  its  accuracy. 
The  diagnosis  of  the  sequelae  is  comparatively  easy. 

Alcoholic  insensibility  differs  from  apoplexy  in  the  following 
points:  insensibility  is  not  so  complete,  no  drawing  in  and 
puffing  out  of  one  cheek  with  respiration,  the  pulse  frequent 
instead  of  slow,  the  pupils  influenced  by  light;  upon  raising 
both  legs,  no  difference  is  apparent  in  allowing  them  to  drop; 
the  eyes  and  head  are  not  turned  to  one  side,  and,  lastly,  the 
condition  is  ameliorated  on  the  inhalation  of  ammonia.  Von 
Wedekind's  test  is  generally  satisfactory:  "  By  simply  pressing 
on  the  supraorbital  notches  with  a  steadily  increasing  force  one 
may,  with  certainty  of  success,  bring  an  unconscious  alcoholic 
to  his  senses,  and  thus  differentiate  between  alcoholic  and  other 
comas." 

Opium  poisoning  differs  from  apoplexy  by  the  gradual 
approach  of  the  coma,  the  contracted  pupil,  slow  pulse,  and  quiet, 
slow  respiration;  the  patient  can  be  momentarily  aroused,  and 
the  heavy  stertor  of  apoplexy  is  absent. 

Uremia  causes  a  coma  that  closely  resembles  apoplexy.  A 
history  of  Bright's  disease  and  the  presence  of  albuminuria  at 
once  clear  up  the  case;  again,  uremic  coma  is  generally  preceded 
by  convulsions ;  a  rapid  rise  of  temperature  is  present  as  shown 
by  the  thermometer,  often  104°  to  106°  F.,  while  to  the  hand  the 


600  CEREBRAL  HEMORRHAGE. 

surface  appears  but  little,  if  at  all,  above  the  normal;  the  pulse 
is  usually  weak  with  irregular  force,  the  respirations  averaging 
25  to  30  per  minute,  and  the  face  having  a  glossy  appearance. 

Cerebral  embolism  cannot  always  be  differentiated  from  apo- 
plexy. We  may  suspect  cerebral  plugging  if  the  patient  be 
young;  if  he  be  laboring  under  acute  or  chronic  cardiac  valvular 
trouble;  if,  within  brief  periods,  several  incomplete  attacks  have 
occurred  before  a  complete  comatose  condition  obtains;  or,  if 
hemiplegia  results  with  passing  or  slight  unconsciousness;  or,  if 
the  phenomena  are  sooner  or  later  followed  by  cerebral  softening, 
since  embolism  and  thrombosis  are  the  most  common  causes  of 
softening. 

Syncope  or  fainting  is  of  sudden  onse.t,  but  being  due  to  a 
failure  of  the  circulation,  the  pulse  is  feeble,  the  face  pale,  the 
respirations  quiet,  and  the  duration  of  unconsciousness  short, 
all  the  very  opposite  of  an  apoplectic  attack. 

Hysteria  may  resemble  apoplexy  at  times  but  the  history,  sex, 
and  other  characteristics  of  hysteria  will  serve  to  make  a  dis- 
tinction. 

Prognosis. — If  the  patient  survive  the  immediate  effects  of  a 
cerebral  hemorrhage,  he  is  always  in  danger  of  another  attack, 
since  the  causes  of  the  original  attack  still  remain.  Another 
attack  or  two  is  the  usual  course,  a  fatal  termination  ultimately 
occurring.  If  the  attack  be  due  to  or  associated  with  Bright's 
disease,  recovery  is  rare.  The  hemiplegia  is  uncertain;  a  partial 
recovery  may  occur  within  a  few  months  or  it  may  continue  for 
years.  The  symptoms  to  be  looked  upon  with  alarm  include 
long-continued  loss  of  consciousness,  abolition  of  reflexes, 
respiratory  disturbances,  disorders  of  the  cardiac  function,  etc. 

Treatment. — If  there  are  prodromal  indications,  the  most 
prompt  means  of  reducing  the  intracranial  blood-pressure  is  by 
venesection,  followed  by  a  brisk  purgative,  which  may  be  aided 
by  an  immediate  enema. 

I^.     Magnesii  sulph Bij  60 .  gm. 

Glycerini f  Sj  30 .  c.c. 

Aqu£e  bull f  §iij  90 .  c.c. 

M.  S. — Administer  by  bowel  slowly  without  force. 


CEREBRAL  HEMORRHAGE.  6oi 

If  the  patient  is  weak,  however,  leeches  should  be  applied  to 
the  mastoid  instead,  and  potassium  bromid,  gr.  xl  to  Ix  (2.6  to 
4  gm.),  or  the  fluidextract  of  ergot,  foss  to  i  (2  to  4  c.c.), 
should  be  administered. 

During  the  attack,  the  clothing  should  be  loosened  and  all  con- 
strictions removed.  The  patient  should  be  placed  in  a  per- 
fectly quiet,  cool  room;  he  should  be  promptly  placed  in  a 
horizontal  position,  with  the  head  somewhat  raised.  The  face 
should  be  a  little  downward,  so  that  the  tongue,  palate,  and 
secretions  may  fall  forward  instead  of  backward  into  the 
pharynx.  An  ice  bag  should  be  applied  to  the  head,  and  a  hot 
mustard  foot-bath  should  be  employed.  Venesection  should  be 
performed  at  once  as  it  aids  in  lessening  the  cerebral  congestion. 
Prompt  catharsis  by  means  of  croton  oil,  rixij  (0.12  c.c),  with 
glycerin,  ttlxv  (i  c.c),  placed  on  the  back  of  the  tongue,  is  also 
advisable;  or  gr,  1/4  (0.016  gm.),  of  elaterium,  dissolved  in  a 
little  water,  may  be  given  in  the  same  way.  If  the  pulse  is 
full  and  strong  after  consciousness  is  regained,  either  tincture 
of-  veratrum  viride  or  tincture  of  aconite  is  indicated.  If,  dur- 
ing the  attack,  the  face  becomes  pallid,  and  the  pulse  irregular, 
and  the  patient  is  prostrated  with  shock,  diffusible  stimulants 
such  as  ammonia  and  ether,  cautiously  employed,  will  be  of 
great  value. 

For  the  secondary  fever,  tincture  of  aconite  or  tincture  of 
veratrum  viride  may  be  used,  and  for  the  headache  and  delirium 
camphor  and  bromids  may  be  employed.  Absorption  of  the 
clot  may  be  hastened  to  some  extent  by  keeping  the  secretions 
active  and  by  the  administration  of  potassium  iodid  or  bi- 
chlorid  of  mercury  alternating  with : 

I^.      Liq.  potassii  arsenit r(\y  .3  c.c. 

Syr.  calcii  lacto-phosph .    f  3ij  8.     c.c. 

M.  S. — Three  times  a  day. 

Subsequent  to  the  attack  the  patient  should  be  placed  on  a 
liquid  or  semisolid  diet.  Absolute  cleanliness  in  the  care  of  the 
patient  is  highly  essential  in  order  to  prevent  the  formation  of 
bedsores.     The  bowels  should  be  moved  daily  and  the  quantity 


6o2  CEREBRAL   THROMBOSIS  AND    EMBOLISM. 

of  urinary  secretion  should  be  carefully  watched.  Bathing 
with  alcohol  serves  to  render  the  patient  very  comfortable. 
Frequently  the  speech  is  lost,  either  temporarily  or  permanently 
and  in  these  cases  the  attendant  should  inquire  after  the  needs 
of  the  patient,  as  otherwise  he  may  be  seriously  neglected. 
After  two  or  three  months  a  weak  galvanic  current  applied 
directly  to  the  head  by  placing  an  electrode  on  each  mastoid 
process  promotes  absorption.  For  the  paralyzed  muscles, 
the  faradic  current,  applied  by  placing  one  electrode  over  or 
near  the  nerve  innervating  the  muscle  and  the  other  over  its 
belly,  acts  as  a  tonic,  preventing  wasting;  it  is  assisted  by 
hypodermic  injections  into  the  paralyzed  muscles  of  strychnin 
sulphate,  gr.  1/64  (0.00 1  gm.),  four  times  a  week.  Massage 
and  warm  salt  baths  are  also  of  value. 

CEREBRAL  THROMBOSIS  AND  EMBOLISM. 

Synonyms. — Partial  cerebral  anemia;  occlusion  of  cerebral 
vessels;  cerebral  softening. 

Definition. — The  occlusion  of  a  cerebral  vessel,  from  the 
formation  of  a  thrombus  or  the  presence  of  an  embolus,  thus 
causing  anemia  of  some  portion  of  the  brain;  characterized  by 
gradual — when  the  result  of  thrombosis — and  sudden — when 
due  to  embolism— development  of  headache,  vertigo,  disorders 
of  intelligence,  with  more  or  less  complete  insensibility  and 
paralysis. 

Causes. — Thrombosis,  or  the  formation  of  a  clot  in  the  vessel 
— an  ante-mortem  coagulation — is  almost  always  the  result  of 
chronic  endarteritis,  as  seen  in  the  aged,  together  with  a  slow- 
ing and  weakening  of  the  blood  current.  Chronic  alcoholism 
and  syphilis  are  the  usual  causes  when  occurring  in  young 
adults. 

Emboli,  in  the  great  majority  of  instances,  result  from  an 
endocarditis — cardiac  emboli;  small  particles  of  the  exudation 
being  carried  into  the  circulation  and  deposited  in  the  brain. 
Emboli  may  also  be  derived  from  an  aortic  aneurysm  or  syph- 
iloma of  the  great  vessels. 


CEREBRAL   THROMBOSIS  AND   EMBOLISM.  603 

Pathologic  Anatomy. — The  cerebral  arteries  may  be  ob- 
structed by  emboli  or  thrombi ;  the  cerebral  veins  and  sinues  by 
thrombi  only.  The  changes  in  the  cerebral  tissue  are  those  of 
anemia  of  the  part  or  parts  supplied  by  the  occluded  vessels. 
The  subsequent  changes  depend  upon  the  anatomy  of  the  ves- 
sels. If  the  obstructed  artery  has  anastomoses,  the  collateral 
circulation  is  soon  established  and  the  brain-tissue  assumes  its 
normal  condition.  If,  on  the  other  hand,  the  occluded  vessel 
be  one  of  "  Cohnheim's  terminal  arteries" — arteries  without 
anastomoses,  such  as  the  lenticular-optic  and  the  lenticular- 
striate  set  of  arteries,  branches  of  the  Sylvian  artery — the 
blood  in  the  whole  extent  of  the  occluded  vessels  coagulates, 

As  a  result  of  the  anatomic  arrangement,  collateral  circula- 
tion is  never  established  and  the  anemic  structure  supplied  by 
the  affected  vessel  dies  or  undergoes  necrobiosis  followed  by 
yellowish-white  softening.  If  the  vessel  beyond  the  seat  of  the 
occlusion  remains  pervious,  blood  flows  back  through  the 
capillaries  from  the  nearest  artery  or  vein,  the  parts  that  a 
short  time  before  were  bloodless  now  become  deeply  engorged, 
the  succeeding  changes  in  the  vessels  permitting  diapedesis  of 
the  red  blood  corpuscles.  The  tissues  which  are  undergoing  dis- 
integration are  colored  by  the  red  corpuscles,  causing  the  appear- 
ance known  as  "red  softening,"  which  after  some  weeks  be- 
comes "  yellow  softening,"  finally  changing  to  "  white  softening," 
when  there  is  a  milky,  or  rather  creamy  fluid  mixed  with  masses 
or  particles  of  broken-down  nerve  elements.  Infective  emboli 
may  produce  abscesses  in  the  brain. 

The  vessel  most  commonly  occluded  is  the  left  middle  cere- 
bral artery,  which  sends  branches  to  the  second  and  third  frontal 
convolutions,  the  anterior  and  superior  portions  of  the  three 
temporal  convolutions,  the  island  of  Reil,  the  parietal  convolu- 
tions, part  of  the  external  and  all  of  the  internal  capsule,  the 
lenticular  nucleus,  and  most  of  the  corpus  striatum  (the  motor 
centers  are  therefore  included). 

Symptoms. — Thrombosis  is  characterized  by  a  gradual  onset. 
It  is  most  common  in  the  aged  and  is  manifested  by  persistent 
headache  and  vertigo   of  varying  intensity;  alterations  in  the 


604  CEREBRAL    THROMBOSIS   AND    EMBOLISM. 

character,  the  patient  becoming  irritable,  morose,  and  despond- 
ent with  periods  of  absent-mindedness;  disorders  of  vision, 
impairment  of  memory;  hesitating  and  mumbling  speech;  im- 
paired locomotion  with  muscular  weakness  and  trembling;  and 
finally  paralysis.  Hemiplegia  is  common  and  may  appear 
gradually  or  be  preceded  by  sudden  insensibility;  the  condition 
progresses  and  ends  in  dementia  and  finally  death  from  exhaus- 
tion. Rarely,  a  collateral  circulation  is  established  and  partial 
or  complete  recovery  occurs. 

In  cerebral  embolism,  the  symptoms  occur  suddenly  and  may 
be  mild  or  grave  in  character. 

In  the  mild  variety,  there  are  sudden  and  severe  vertigo,  con- 
fusion of  mind,  muscular  twitchings,  usually  one-sided,  and  vom- 
iting, followed  by  hemiplegia,  most  frequently  of  the  right  side, 
the  intellect  remaining  clear  but  hesitating.  After  some  weeks 
or  months  the  paralysis  usually  disappears  and  recovery  is 
complete. 

The  grave  or  apoplectic  variety  is  manifested  by  sudden  head- 
ache, vertigo,  flushing  or  pallor  of  the  face,  sudden  unconscious- 
ness, often  preceded  by  a  sharp  cry,  and  complete  muscular  re- 
laxation followed  by  death,  or  a  gradual  return  to  consciousness 
with  hemiplegia,  usually  right-sided,  and  aphasia.  The  loss  of 
speech  may  last  several  weeks  or  months  or  may  be  persistent. 
The  mind  may  remain  normal  or  may  be  greatly  enfeebled,  the 
reason  and  judgment  be  clouded,  and  after  a  varying  period 
dementia   develops,   being  followed  by  exhaustion  and  death. 

The  following  localizing  signs  will  serve  to  determine  the  situa- 
tion of  the  obstruction: 

Vertebral  artery,  the  left  most  frequently,  when  obstructed  re- 
sults in  acute  bulbar  paralysis  from  involvement  of  the  nuclei  in 
the  medulla,  with  or  without  hemiplegia. 

Basilar  artery  obstruction  causes  diplegia  with  bulbar  symp- 
toms. There  is  rapid  rise  of  temperature.  Death  follows  within 
a  day  or  two,  or  suddenly,  if  the  respiratory  centers  are  involved. 

Middle  cerebral  artery  or  one  of  its  branches  is  the  most  fre- 
quent seat  of  embolic  or  thrombotic  occlusions.  The  symptoms 
depend  upon  the  exact  branch  involved;  if  plugged  before  the 


CEREBRAL    THROMBOSIS   AND    EMBOLISM.  605 

central  arteries  are  given  off,  the  internal  capsule  is  deprived  of 
its  blood  supply  and  permanent  hemiplegia  may  follow;  if  the 
blocking  is  in  the  central  branches,  the  hemiplegia  involves  the 
arm  and  face,  and  if  the  left  side,  aphasia  occurs.  The  individual 
branches  passing  to  the  third  frontal  (aphasia),  the  ascending 
parietal  (hemiplegia),-  supramarginal  and  angular  gyri  (word 
blindness),  and  the  temporal  gyri  (word  deafness),  may  be 
plugged. 

Duration. — Thrombosis  is  essentially  an  affection  of  the  elderly 
and  has  a  chronic  course.  Months  and  years  may  be  occupied 
with  the  various  symptoms  until  the  phenomena  of  secondary 
dementia  develop. 

Embolism  is  of  sudden  onset,  and  may  be  followed  by  a  rapid 
recovery. 

Diagnosis. — Caille  gives  the  following  differential  diagnosis: 

"  Cerebral  Hemorrhage  occurs  after  the  age  of  fifty-five,  as 
a  rule,  with  atheromatous  arteries  and  an  hypertrophied  heart. 
.The  onset  is  sudden,  with  coma,  during  exertion  or  excitement. 
The  temperature  falls  in  an  hour,  and  then  rises,  sometimes  to 
106°  F.  Gradual  recovery  of  consciousness  takes  place  in 
from  three  to  five  days,  with  permanent  hemiplegia. 

''Cerebral  embolism  comes  at  any  age,  with  heart  disease  or 
after  childbirth.  There  is  a  sudden  onset,  without  loss  of 
consciousness  or  with  slight  mental  confusion,  or  with  rapid 
return  to  consciousness.  The  temperature  does  not  fall,  but 
may  rise  as  high  as  102°  F.  Improvement  occurs  within  twenty- 
four  hours  to  a  marked  degree,  but  after  three  or  four  days  the 
symptoms  return.  Monoplegia,  hemiplegia,  or  aphasia  may 
remain.  Jacksonian  epilepsy  may  develop  if  the  lesion  is 
cortical,  involving  a  special  center. 

"  Cerebral  thrombosis  occurs  at  any  age,  but  chiefly  in  syphil- 
itic persons  and  middle-aged  men.  There  are  usually  premoni- 
tions. The  onset  is  slower,  without  coma,  but  with  dullness  of 
the  mind.  The  temperature  does  not  fall,  but  may  rise  to 
100°  F.      The  paralysis  is  similar  to  that  observed  in  embolism. 

"  The  diagnosis  between  these  three  conditions  is  hardly  ever 
positive." 


6o6  CEREBRAL    THROMBOSIS   AND    EMBOLISM. 

Prognosis.  —  Thrombosis  is  a  permanent  and  progressive 
condition  in  the  majority  of  instances.  Recovery  is  a  rare 
termination. 

Embolism  may  be  followed  by  a  perfect  recovery.  Usually, 
however,  some  evidences  of  the  plugging  remain  permanently. 
Death  may  be  the  result  within  a  day  or  two,  from  the  plugging 
of  a  large  vessel,  the  patient  never  emerging  from  the  coma.  In 
other  cases  the  patient  arouses  from  the  coma,  the  hemiplegia 
with  aphasia  persisting,  and  the  case  pursues  the  usual  course 
of   localized    cerebral    softening. 

Treatment. — Blood-letting  is  contraindicted.  The  indication 
in  the  early  stage  of  embolism  and  thrombosis  is  to  reestablish 
the  circula+ion  within  the  area  deprived  of  its  blood  supply, 
in  order  to  prevent  the  changes  incident  to  defective  nutrition; 
this  is  accomplished  by  measures  to  strengthen  the  heart's 
action,  tonics,  perfect  rest  for  some  time  after  the  attack,  a 
plain  but  nutritious  diet,  and  attention  to  the  various  secretions. 
Bartholow  advises  the  administration  of  ammonium  carbonate, 
gr.  X  (0.6  gm.),  and  ammonium  iodid,  gr.  v  (0.3  gm.),  three 
times  daily  over  a  long  period,  the  objects  being  to  increase  the 
action  of  the  heart  and  arteries,  and  to  effect  a  solution  of  the 
thrombus  by  maintaining  the  alkalinity  of  the  blood.  Rest  in 
bed  with  the  head  elevated  should  never  be  neglected  in  these 
cases.  In  cases  in  which  syphilis  is  a  factor,  potassium  or 
sodium  iodid  and  mercury  should  be  given.  Stimulants  in 
moderate  doses  are  of  value. 

In  the  aged,  presenting  indications  of  degeneration,  much 
benefit  results  from  the  use  of: 

I^.     Liquor,  potassii  arsenitis.  .  .  .     n^iij  .2  c.c. 

Syr.  calcii  lacto-phosphat .  ,  .  .    f  5ij  8.     c.c. 

M.   S. — After  meals,   well  diluted. 

It  may  be  combined  with  cod-liver  oil  with  decided  advantage. 
For  embolism,  the  immediate  and  persistent  use  of  the  follow- 
ing may  dissolve  the  plug: 

I^.      Ammonii  carbonat gr.  v  .3  gm. 

Liquor,  ammonii  acetatis  f5j  4.     c.c. 

M.  S. — Three  or  four  times  daily,  well  diluted. 


CEREBRAL  ABSCESS.  607 

CEREBRAL  ABSCESS. 

Synonyms. — Acute    encephalitis;    suppurative    encephalitis. 

Definition. — An  acute  suppurative  inflammation  of  the  brain 
structure,  either  localized  or  diffused,  primary  or  secondary; 
characterized  by  impairment  of  intellect,  sensation,  and 
motion. 

Causes. — Primary  cerebral  abscess  is  exceedingly  rare,  and  is 
due  to  pyemia,  glanders,  and  embolus  from  ulcerative  endo- 
carditis. 

Secondary  cerebral  abscesses  result  from  injuries  to  the  cerebral 
tissues,  following  apoplexy,  embolism,  thrombosis,  and  injuries 
to  the  cranial  bones,  chronic  suppurative  otitis,  and  chronic 
suppuration  in  some  other  portion  of  the  body. 

Pathologic  Anatomy. — Abscesses  of  the  brain  may  be  single 
or  multiple,  varying  in  size  from  an  almond  to  an  egg. 

They  occupy  a  limited  and  well-defined  region  of  the  cerebral 
tissue,  such  as  either  the  corpora  striata,  optic  thalami,  gray 
matter  of  the  cortex,  the  cerebellum,  or  the  white  matter  of  the 
hemispheres.  Cerebral  abscesses  are  usually  due  to  micro- 
organisms and  are  more  frequent  in  the  right  hemisphere  than 
the  left.  When  the  result  of  pyemia  or  infection  from  distant 
organs,  such  as  the  lungs,  they  are  generally  multiple.  AVhen 
secondary  to  disease  of  the  ear,  frontal  sinuses,  naso-pharynx, 
or  trauma,  they  are  usually  single. 

An  abscess  having  developed,  steadily  increases  in  size, 
encroaching  upon  the  surrounding  brain,  and  usually  the  brain 
tissue  forms  a  defensive  wall  about  the  abscess- — a  capsule  or 
pyogenic  membrane.  The  encapsulated  abscess  continues  to 
develop,  and  finally  bursting,  infiltrates  the  surrounding  tissue 
vv^ith  consequent  pressure,  or  discharges  into  the  meshes  of  the 
pia-arachnoid,  on  the  cortex,  or  into  the  lateral  ventricles. 
Rarely,  an  encapsulated  abscess  may  become  permanently 
encysted.  The  pus  of  cerebral  abscess  is  greenish  or  greenish 
yellow  in  color,  and  fetid  (Dercum). 

Symptoms. — A  concise  description  of  the  symptoms  of  ab- 
scess of  the  brain  is  very  difficult,  on  account  of  the  wide  varia- 


6o8  CEREBRAL  ABSCESS. 

tions  dependent  on  its  location,  and  also  the  difficulty  of  isolating 
it  from  the  affections  to  which  it  is  secondary. 

The  onset  varies  according  to  the  cause,  although  all  cases  are 
associated  with  headache,  irritative  fever,  vomiting,  persistent 
and  spreading  paralysis,  convulsions,  optic  neuritis,  mental 
apathy,  delirium,  and  coma. 

If  consecutive  to  apoplexy,  thrombosis,  or  emboli,  there  occur 
fever  and  delirium,  the  paralysis  remaining  and  spreading  with 
spasmodic  contractions  of  the  affected  muscles. 

If  secondary  to  a  chronic  ear  disease,  there  is  sudden  cessation 
of  the  ear  discharge ;  severe  pain  in  ear  and  side  of  head,  accom- 
panied with  chill,  fever,  vomiting,  followed  in  a  few  days  by  the 
disappearance  of  febrile  symptoms  and  the  development  of  a 
condition  of  stupor,  with  cerebral  symptoms,  depending  upon 
the  location  of  the  abscess. 

Occasionally,  cases  run  a  chronic  course  with  rather  insidious 
onset,  dull,  persistent  headache;  changed  disposition,  peevish, 
irritable,  unreliable,  with  decline  of  moral  sensibility;  easily 
fatigued  by  mental  work;  inability  to  stand  exertion;  impaired 
memory;  vertigo;  and  dyspepsia;  soon  followed  by  slight  palsies, 
which  progressively  increase,  becoming  general,  with  involun- 
tary discharges,  death  following  from  exhaustion. 

Of  the  focal  symptoms,  hemiplegia,  of  incomplete  character, 
occurs  in  about  one-half  of  all  cases  of  abscess  of  the  brain. 
A  very  constant  symptom  of  diagnostic  value,  when  hemiplegia 
is  very  marked  is  exaggerated  knee-jerk  with  pronounced 
ankle  clonus. 

Diagnosis. — A  positive  diagnosis  is  only  possible  by  a  close 
study  of  the  causes  and  the  clinical  history,  as  the  symptoms  at 
times  indicate  meningitis  and  again  cerebral  tumor. 

Purtilent  meningitis  may  follow  trauma  to  the  brain  or  chronic 
ear  disease,  making  the  diagnosis  impossible.  The  chief  points 
of  distinction  are:  The  subacute  or  chronic  course  of  abscess, 
slight  involvement  of  cranial  nerves,  hemiplegia,  and  the 
presence  of  an  active,  persistent,  unilateral  ankle  clonus  and 
exaggerated  knee-jerk  on  paralyzed  side. 

Prognosis. — The  usual  termination  is  in  death.     The  course 


CERE  UK  A  L    TUMOR.  ()0<) 

depends  u]j(m  the  character  and  exteni"  of  the  injury,  varying 
from  a  few  days  to  several  months. 

Treatment. — Surgical  treatment  has  been  attended  with 
marked  success  in  some  cases  of  abscess  of  the  brain,  the  with- 
drawal of  the  pus  being  followed  by  recovery.  For  traumatic 
abscess  the  operation  of  trephining  is  indicated.  When  opera- 
tion is  for  any  reason  impracticable,  the  treatment  is  purely 
symptomatic. 


CEREBRAL  TUMOR. 

Synonym. — Intracranial  tumor. 

Definition. — Tumor  of  the  brain  is  either  a  growth  in  the 
cerebral  tissue,  on  the  meninges,  or  in  the  vessels,  and  is  char- 
acterized by  symptoms  of  pressure  upon  the  brain  structure. 

Causes. — The  most  important  etiologic  factors  are  male  sex, 
middle  age,  heredity,  injuries  to  the  head,  vascular  changes, 
syphilis,  tuberculosis,  and  cancer. 

Pathology. — Tumors  of  the  brain  are  of  various  kinds,  viz., 
vascular  tumors,  aneurysms;  parasitic  tumors,  cysticercus;  dia- 
thetic tumors,  tubercle  or  syphilis;  accidental  tumors,  glioma. 
The  most  common  cerebral  growths  are  tubercle,  syphiloma, 
glioma,  sarcoma,  carcinoma,  and  cysts.  The  size  of  the  tumors 
varies  and  they  may  attain  the  size  of  an  orange  before  they 
induce  symptoms.  All  growths  of  the  brain  produce  irritation 
of  the  surrounding  parts  at  first,  and  later  by  pressure  give  rise 
to  interference  with  the  blood  supply  and  destruction  of  the 
tissues. 

Symptoms. — Those  common  to  all  cerebral  tumors  are :  Head- 
ache, persistent  and  increasing  in  intensity;  defects  of  vision, 
even  blindness,  due  to  an  optic  neuritis,  a  very  constant  symp- 
tom; defects  of  hearing,  taste,  and  of  speech,  the  result  of  paresis 
of  the  vocal  cords;  vertigo,  associated  with  nausea  and  vomiting 
and  convulsions,  epileptiform  in  character.  These  convulsions 
are  usually  limited  to  one  side  of  the  body  and  occur  at  regular 
intervals.  They  may  be  localized  (Jacksonian  epilepsy)  to  one 
39 


6lO  CEREBRAL   TUMOR. 

or  more  groups  of  muscles  and  are  never  attended  with  loss  of 
consciousness.  Nystagmus  is  sometimes  present.  Palsies  such 
as  strabismus,  ptosis,  dilatation  of  the  pupil,  facial  palsy,  para- 
plegia, and  hemiplegia  are  not  uncommon  symptoms.  Defects 
of  sensibility  such  as  sensations  of  numbness  and  coldness  in  the 
limbs  and  body  may  also  occur.  Occasionally,  there  are  dis- 
turbances of  equilibrium,  manifested  by  a  tendency,  when 
standing,  to  go  backward  or  turn  to  the  right  or  left.  The 
intellectual  faculties  may  be  well  preserved  until  late  in  the 
affection  when  irritability  of  temper,  .  depression  of  spirits, 
impairment  of  memory,  emotional  disturbances,  and  a  gradually 
advancing  dementia  may  develop.  Slowing  of  the  pulse,  in- 
somnia, and  increased  secretion  of  urine  sometimes  accompany 
cerebral  tumors. 

Diagnosis. — A  positive  diagnosis  can  rarely  be  made.  The 
following  points  will  aid:  Long-continued  persistent  headache, 
without  appreciable  cause;  unilateral  epileptiform  convulsions, 
without  loss  of  consciousness;  difficulty  of  vision,  hearing,  and 
speech,  associated  with  nausea  and  vomiting,  and  local  and 
general  palsies. 

The  location  of  the  tumor  may  be  determined  by  the  more  or 
less  pronounced  character  of  certain  symptoms. 

The  diagnosis  of  the  character  of  the  growth  can  only  be  deter- 
mined by  a  close  study  of  the  history. 

According  to  Herter ,  the  indications  which  suggest  that  the 
tumor  is  a  syphilitic  growth  are  as  follows:  Syphilitic  history; 
symptoms  of  irritative  disease  of  cortex  rather  than  destruc- 
tive evidences  of  rapid  growth  at  the  onset,  followed  by  a  period 
of  slow  progress  or  stationary. symptoms;  gradual  improvement 
under  antisyphilitic  treatment;  development  between  twenty 
and  forty-five  years  of  age. 

Indications  suggesting  tubercular  growth  are:  Family  history, 
or  tuberculosis  in  some  other  organ  of  the  patient;  rapid  de- 
velopment of  symptoms;  indications  of  the  growth  in  the  cere- 
bellum or  in  the  pons;  early  appearance  of  the  symptoms,  espe- 
cially before  the  tenth  year,  and  history  of  injury  to  head. 

Indications  suggesting  sarcoma  ov  cancer  are:    The  presence 


CEREBRAL   TUMOR.  6ll 

of  a  sarcoma  elsewhere  and  rapidly  failing  health,  with  cerebra 
tumor  symptoms  in  patient  over  fifty  years. 

Indications  suggesting  glioma:  Sudden  loss  of  consciousness 
with  exacerbation  of  all  symptoms  in  the  clinical  history  of  cere- 
bral tumor;  cortex  irritative  symptoms  as  in  syphiloma,  develop- 
ing under  fifty  years  of  age,  and  the  absence  of  all  evidences  of 
tubercle,  syphilis,  sarcoma,  and  cancer. 

The  focal  symptoms  of  intracranial  tumors  are  so  important 
in  diagnosis  that  the  following  summary  of  symptoms  caused 
by  brain  tumors  is  given : 

Prefrontal  region.  If  on  the  right  side,  there  may  be  no 
symptoms  at  all;  mental  impairment;  pressure  in  central 
region,  causing  aphasia,  Jacksonian  epilepsy,  and  disturbances 
of  smell. 

Central  region.  Motor  aphasia,  monoplegia,  partial  anes- 
thesia, Jacksonian  epilepsy. 

Posterior  parietal  region.  Word-blindness,  homonymous  hemi- 
anopsia, disturbed  muscular  sense. 

Corpus  callosuni.     Progressive  hemiplegia. 

Crus  cerebri.  Crossed  paralyses  of  oculomotor  nerve  and 
limbs. 

Corpora  quadrigemina.  Oculomotor  paralyses,  reeling  gait, 
possibly  blindness  and  deafness. 

Pons  and  medulla.  Crossed  paralysis  of  face  and  limbs,  or 
tongue  and  limbs.     Other  lesions  in  cranial  nerves. 

Cerebellum.  Marked  cerebellar  ataxia,  vomiting,  convul- 
sions, coma. 

Base,  anterior  fossa.  Mental  enfeeblement,  disturbances  of 
smell  and  vision,  and  exophthalmos. 

Base,  middle  fossa.  Impairment  of  vision;  hemiplegia; 
oculomotor  disturbances. 

Base,  posterior  fossa.  Trigeminal  neuralgia;  neuro-para- 
lytic  ophthalmia;  paralysis  of  the  face  and  tongue;  impaired 
hearing;  crossed  paralyses. 

Diagnosis  between  cerebral  tumor  and  abscess.  Both  may 
have  any  or  all  of  the  following  symptoms:  Headache,  vomit- 
ing, double  optic  neuritis,  and  mental  failure.     Tumor  has,  in 


6l2 


CEREBRAL    TUMOR. 


addition,  marked  focal  symptoms,  monoplegia,  hemiplegia, 
paralysis  of  cranial  nerves,  and  marked  optic  neuritis;  the  ab- 
sence of  these  favors  abscess.  If  the  hemiplegia  is  due  to  ab- 
scess, the  ankle  clonus  and  knee-jerk  are  exaggerated.  Fever 
and  rigors  point  to  abscess.  The  causes  of  abscess  are  very 
clear,    those  of  tumor  often  uncertain. 

The     differential     diagnosis    between    tumor,     abscess,     and 
tuberculous  meningitis  is  given  in  the  following  table  (Turner) : 


Tumor. 


Abscess. 


Meningitis. 


History  indefinite. 


Otorrhea    or    other   suppur-     Tuberculous  history  or  diath- 
ative  condition.  esis. 


Onset  gradual Onset  usually  abrupt Onset  rapid. 


Optic  neuritis  usually  well 
marked. 

Monoplegia,  hemiplegia,  or 
localized  convulsions,  in 
definite  order. 

Febrile  symptoms  absent. 


Duration  months  to  years; 
regular  course. 


Optic  neuritis  usually  absent  Optic  neuritis  rare, 
or  late. 

Focal  symptoms  indicative  of  Irregular    palsies    and    con- 
cerebellum  or  temporal  lobe  vulsions. 


Temperature  sometimes  sub-  Temperature  irregular, 
normal. 

Duration  variable  with  latent  Duration  of  weeks,  at  times 
periods.  irregular. 


Prognosis. — Except  in  cases  of  syphilitic  orgin  the  prognosis  is 
very  unfavorable  and  even  in  syphiloma  the  termination  may 
be  fatal  if  the  treatment  is  not  prompt. 

Treatment. — This  is  unsatisfactory  and  consists  largely  in 
measures  for  the  relief  of  the  symptoms.  As  benefit  occasionally 
follow^s  the  use  of  potassium  iodid,  gr.  xx  (1.3  gm.),  three  times 
daily,  and  also  fiuidextract  of  ergot,  foss  to  i  (2  to  4  c,c.), 
three  times  a  day,  increased  until  their  full  physiologic  effects 
are  produced;  these  remedies  should  be  used  in  all  cases,  dis- 
continuing them  if  no  benefit  follows  a  prolonged  trial.  When 
the  evidences  of  syphilis  are  unmistakable,  the  mercurials 
should  be  given,  in  addition,  pushed  to  their  point  of  tolerance. 
When  the  tumor  can  be  localized  and  is  accessible,  surgical 
intervention  is  indicated. 


APHASIA.  613 

APHASIA. 

Definition. — The  loss,  partial  or  complete,  of  the  power  of 
expression  or  comprehension  of  language.  A  loss  of  memory 
for  words.      Aphasia  is  a  symptom  and  not  a  disease. 

Amnesic  aphasia,  or  loss  of  the  memory  of  words  by  which 
ideas  are  expressed. 

Ataxic  aphasia,  the  inability  to  combine  the  different  parts 
of  the  vocal  apparatus  for  vocal  expression,  although  the 
memory  of  words  still  remains,  so  that  the  afflicted  person  can 
write  his  ideas  intelligently. 

Agraphia,  the  inability  to  recognize  and  make  signs  by  which 
ideas  are  communicated  in  written  language. 

Paraphasia,  the  mental  state  in  which  the  wrong  words  are 
used  to  express  an  idea. 

Paragraphia,  the  state  in  which  wrong  or  meaningless  written 
signs  are  used  to  express  an  idea. 

There  are  four  centers  concerned,  two  motor,  and  two  sen- 
sory. The  two  motor  centers  are:  (ij  Broca's  center,  for 
speech;  and  (2)  that  for  writing,  in  the  posterior  part  of  the 
second  left  frontal  convolution.  The  two  sensory  centers 
are:  (3)  The  auditory  word  center,  in  the  posterior  part  of  the 
first  temporal  convolution;  and  (4)  the  visual  word  center,  in 
the  angular  gyrus.  Lesions  of  (i)  cause  motor  aphasia;  the 
patient  cannot  express  himself  in  words,  but  he  can  understand 
what  is  said  to  him.  Lesions  of  (2)  cause  agraphia.  Lesions 
of  (3)  cause  word-deafness;  the  patient  can  hear,  but  does  not 
understand  what  he  hears.  Lesions  of  (4)  cause  alexia  or  word- 
blindness;  the  patient  can  see,  but  cannot  read  print.  The  chief 
differences  between  motor  and  sensory  aphasia  are  given  in  the 
following  table  (from  Wheeler  and  Jack) : 


6i4 


APHASIA. 


Motor  aphasia. 


Sensory  aphasia  (verbal  amnesia). 


Word-deafness. 


Word-blindness. 


Patient  almost  completely! 
loses  power  of  speech.' 
Words  like  oaths,  "  yes," 
or  "no,"  may  be  re- 
tained. 

Understands  what  is  said 
to  him. 


Can  still  speak,  sometimes 
with  little  aphasia,  but 
sometimes  merely  gibberish. 


Does   not   understand   what 
is  said. 


Cannot  repeat  words i   Cannot  repeat  words. 


Recognizes  written  words 
but  cannot  write  them. 
Cannot  copy  print  into 
writing,  though  he  may 
copy  letters  (aphasia 
and  agraphia).  Rarely 
can  write  (aphasia  with- 
out agraphia). 

Is  aware  of  his  errors — ^he 
can  recall  words  but  not 
utter  them. 

Mental  impairment  is  buti 
sUght. 


May  be  some  word  blindness 
and  agraphia,  or  patient 
may  recognize  and  write 
words  freely. 


Is  unaware  of  his  errors 
of  speech — ^auditory  word 
memory  is  destroyed.  j 


Speech  little  affected. 


Understands  what  is  said. 


Can  repeat  words. 

Cannot  recognize  written  or 
printed  words,  or  write 
them  (agraphia) .  May 
recognize  letters,  or  his  own 
name.  If  the  damage  is 
partial,  may  write  wrong 
words  or  in  wrong  order 
{paragraphia) . 

Is  unaware  of  his  errors  in 
writing  visual  word  memory 
is  destroyed. 


Mental 
marked. 


impairment      is! 


Mental 
slight. 


impairment     i  s 


Pathologic  Anatomy. — Aphasia  is  not  the  result  of  any  one 
specific  lesion,  but  occurs  during  the  course  of  several,  viz., 
Occlusion  of  certain  cerebral  vessels;  cerebral  hemorrhage; 
cerebral  abscess  or  softening;  meningitis;  tumors;  mental  or 
moral  causes;  hysteria. 

It  is  now  almost  definitely  determined  that  lesions  of  the 
left  middle  cerebral  artery,  island  of  Reil,  third  frontal  con- 
volution, and  parts  of  the  corpus  striatum  are  associated  in 
the  production  of  aphasia.  The  lesions  are  usually  upon  the 
left  side  of  the  brain,  the  aphasia  being  often  associated  with 
right  hemiplegia. 

Symptoms. — The  degree  to  which  articulate  language  is  im- 
paired varies  from  the  loss  of  a  few  words  to  complete  inability 
to  communicate  ideas.  The  intellect  does  not  suffer  in  propor- 
tion to  the  loss  of  words;  for,  showing  the  individual  an  article, 
while  he  may  miscall  it,  if  it  is  called  by  name  he  will  recognize 
it.  This  inability  to  convey  thoughts  is  a  source  of  great  men- 
tal suffering,  in  some  leading  to  a  suicidal  tendency. 


VERTIGO.  615 

A  strange  clinical  fact  is  the  strong  tendency  to  profanity 
shown  by  aphasic  patients. 

Diagnosis. — Aphonia,  or  loss  of  voice  should  not  be  con- 
founded  with   aphasia,    or   the   inability   to   remember  words. 

Paralysis  of  the  tongue,  or  inability  to  move  this  organ,  thereby 
interfering  with  articulate  language,  should  not  be  confounded 
with  aphasia,  which,  as  a  rule,  is  not  associated  with  paralysis 
of  the  tongue. 

Prognosis. — The  outlook  is  controlled  entirely  by  the  cause. 
If  the  result  of  congestion  of  the  brain  or  a  syphilitic  tumor, 
the  prognosis  is  favorable.  If  associated  with  hemiplegia,  the 
clot  may  undergo  absorption,  and  recovery  follow.  If  associated 
with  softening  of  the  brain,  however,  the  disease  grows  progress- 
ively worse. 

Treatment. — The    cause    must    be    energetically    treated,    as 

the  aphasia  pursues  a  course  parallel  to  the  associated  malady. 

Cases  not   associated  wth  cerebral  softening  have  regained  the 

memory  of  words  by  a   course  of  carefully  conducted  speech 

'lessons. 

When  the  aphasia  is  of  sudden  occurrence  it  is  strongly  sig- 
nificant of  injury  to  the  brain  by  a  spicule  of  bone  or  the  pres- 
sure of  a  blood  clot,  particularly  in  those  cases  in  which  there 
is  a  history  of  a  head-wound.  In  these  instances,  the  operation 
of   trephining   may   be   of   benefit   and   should   be   considered. 

VERTIGO. 

Synonym. — Dizziness. 

Definition. — Vertigo,  or  dizziness,  is  a  subjective  state,  in 
which  the  individual  affected  (subjective  vertigo),  or  the  objects 
a.bout  him  (objective  vertigo),  seem  to  be  in  rapid  motion,  either 
of  a  rotar^^  circular,  or  to-and-fro  character. 

Causes. — The  etiology  of  an  attack  of  vertigo  depends  upon 
the  particular  .variety. 

Ocular  vertigo  results  from  the  paresis  of  one  or  more  of  the 
ocular  muscles,  eye-strain,  or  astigmatism. 

Aural   or  auditory  vertigo  or  Menihe's  disease,   results  from 


6l6  VERTIGO. 

disease  of  the  semicircular  canals  and  cochlea.  Meniere's 
disease,  so-called,  is  a  sudden  severe  vertigo,  the  result  of 
either  a  hemorrhage  or  a  serous  or  purulent  exudation  into  the 
semicircular  canals. 

Gastric  vertigo  is  the  most  common  variety  and  results  from 
either  stomachic  or  intestinal  dyspepsia,  disordered  hepatic  func- 
tion, or  constipation.  "  The  mechanism  of  the  vertigo  is  com- 
plex. There  are  two  factors:  one  consists  in  the  toxic  effect  of 
the  imperfectly  oxidized  materials  which  accumulate  in  the 
blood;  the  other  is  reflex.  An  impression  made  on  the  end 
organs  of  the  pneumogastric  in  the  stomach  is  reflected  over 
the  sympathetic  ganglia"    (Bartholow). 

Nervous  vertigo  is  associated  with  migraine,  sick  or  nervous 
headache,  and  may  be  caused  by  physical  or  nervous  excesses, 
and  also  by  the  immoderate  use  of  tea,  coffee,  alcohol,  and 
tobacco.  It  is  also  a  result  of  many  of  the  organic  diseases  of 
the  brain. 

Senile  vertigo  is  the  result  of  the  disordered  cerebral  circula- 
tion   resulting    from    senile  changes  in  the  heart  and  vessels.' 

Symptoms. — In  all  varieties  of  vertigo,  the  symptom  of  a 
sensation  of  objects  moving  around  the  patient,  or  the  patient  mov- 
ing around  objects  which  remain  stationary,  is  present  in  some  de- 
gree. The  attack  of  giddiness  comes  on  suddenly,  with  an 
indistinctness  of  vision  and  slight  confusion  of  the  thoughts. 
The  patient  may  fall  unless  he  grasps  something  to  steady  him- 
self. Nausea  and  vomiting  and  cardiac  palpitation  with  tin- 
nitus aurium  are  often  associated  with  the  vertiginous  sensa- 
tions.     There  is  no  loss  oj  consciousness. 

In  the  ocular  vertigo,  the  attack  is  usually  the  result  of  read- 
ing, writing,  sewing,  or  other  close  application  of  the  eyes,  the 
ordinary  symptoms  of  vertigo  being  preceded  by  headache, 
nausea,  specks  before  the  eyes,  and  pain  in  the  eyeballs. 

In  Meniere's  disease,  the  vertigo  is  associated  with  serious 
tinnitus  aurium,  and  the  vertiginous  sensations  are  of  various 
forms  such  as  a  see-saw  movement,  a  gyratory  motion,  right  or 
left;  a  vertical  whirl,  or  a  sensation  of  rising  and  falling  like 
the  swell  of  the  ocean.     The  symptoms  are  of  long  durat"on, 


VERTIGO.  6 1  J 

becoming  marked  in  paroxysms.  The  attack  of  aggravated 
vertigo  is  so  sudden  and  overwhelming  at  times,  that  the  person 
is  suddenly  thrown  to  the  ground  as  if  struck  with  a  blow,  and 
is  associated  with  nausea  and  vomiting.  As  the  condition 
continues,  the  character  of  the  individual  changes,  becoming 
morose,  irritable,  and  suspicious.  Not  all  cases  of  Meniere's 
disease  become  permanent;  it  may  occur  in  isolated  attacks, 
the  interval  being  free  from  all  sensations. 

Gastric  vertigo  is  by  far  the  most  frequent  variety.  Persons 
subject  to  vertigo  of  this  kind  live  in  constant  dread  of  cerebral 
disease,    which    fear    frequently    results    in    true    melancholia. 

The  vertiginous  sensations  usually  occur  during  the  course 
of  well-marked  and  long-standing  stomach  and  intestinal 
disorders,  such  as  pain  or  oppression  after  meals,  nausea, 
pyrosis,  heartburn,  frequent  eructations,  and  constipation  or, 
rarely,  diarrhea.  The  abdomen  is  often  distended  with  flatus. 
Great  pain  in  the  nucha  is  a  very  frequent  occurrence.  The 
attack  may  be  associated  with  either  hyperemia  or  anemia  of 
the  brain.  The  symptoms  are  not  constant,  but  recur  at  inter- 
vals,   sometimes   remote,    at   others   very   close   to   each   other. 

In  nervous  vertigo  the  vertiginous  symptoms  are  usually  asso- 
ciated with  more  or  less  irritability  of  temper,  restlessness, 
and  insomnia.  The  onset  is  sudden,  after  some  one  of  the 
etiologic  factors.  In  megrim  there  are  headache,  nausea,  and 
vomiting.  This  form  of  vertigo  often  precedes  or  replaces  the 
epileptic  convulsion.  And  it  also  often  precedes  softening  of 
the  brain. 

In  senile  vertigo  the  vertiginous  symptoms  are  the  result  of 
anemia  of  the  brain.  The  attacks  are  developed  by  an  exertion, 
often  by  merely  assuming  the  erect  posture.  There  is  a  swim- 
ming sensation  in  the  head,  and  darkness  falls  on  the  eyes,  with 
a  sensation  of  chilliness  and  prostration. 

Diagnosis. — The  diagnosis  of  the  various  forms  of  vertigo  can 
only  be  determined  after  a  close  study  of  the  history  and  course 
of  the  attack.  The  existence  of  organic  cerebral  disease  must 
always  be  kept  in  mind  in  solving  any  case. 

Prognosis. — This   will   be   influenced   by   the   variety   of   the 


6l8  VERTIGO. 

vertigo.  The  prognosis  is  favorable  in  ocular  and  gastric  ver- 
tigo. Unless  the  result  of  organic  disease,  the  prognosis  is  good 
in  nervous  vertigo.  In  auricular  vertigo  teh  prognosis  is  fair, 
but  in  genuine  Meniere's  disease  the  prognosis  is  unfavorable, 
as  it  also  is  in  senile  vertigo. 

Treatment. — In  all  persistent  cases,  the  eyes  should  be 
examined  under  the  influence  of  a  cycloplegic  and  the  state  of 
refraction  and  muscle-balance  carefully  ascertained.  Correct- 
ing lenses  should  be  ordered  for  the  most  trivial  ametropic 
condition  under  such  circumstances,  and  their  adjustment 
should  receive  careful  attention. 

When  the  vertigo  is  that  of  Meniere's  disease,  rest  in  the  re- 
cumbent posture  and  the  administration  of  quinin  sulphate,  gr. 
X  to  XV  (0.6  to  I  gm.),  daily,  'until  cinchonism  is  produced  is 
advised  (Charcot).  In  cases  of  syphilitic  origin  the  iodids  may 
be  employed.  Potassium  bromid  and  the  salicylates  are  at 
times  of  value. 

In  gastric  vertigo,  the  diet  should  be  carefully  regulated.  At 
the  beginning  of  the  treatment  it  is  often  of  great  advantage  to 
place  the  patient  on  an  exclusively  milk  diet,  gradually  widening 
the  variety  as  improvement  occurs.  In  these  cases  a  course  of 
arsenic  is  often  serviceable.  If  the  digestion  be  torpid,  the  tinc- 
ture of  nux  vomica  is  indicated.  If  the  bowels  are  constipated, 
benefit  is  obtained  from  fluid  extract  of  cascara. 

Glycerini f§j  30.  c.c. 

I^.     Fluidextract.  cascarae  sagr.   fSj  30.  c.c. 

Tinct.  card,  comp f  §ss  15 .  c.c. 

Aquae  menthae  pip f  5ss  15.  c.c. 

M.   S. — One  teaspoonful  three  times  daily,  well  diluted. 

For  nervous  vertigo,  the  exciting  cause  should,  if  possible,  be 
removed  and  such  remedies  as  iron,  quinin,  and  strychnin,  either 
alone  or  in  various  combinations,  should  be  administered. 
Many  of  these  cases  can  be  traced  to  the  other  causes  of  vertigo 
and  consequently  the  treatment  is  subject  to  many  and  great 
variations. 

For  senile  vertigo,  a  highly  nutritious  diet  with  the  judicious 


MIGRAINE.  619 

use  of  whiskey  is  indicated.  Other  tonics,  particularly  bichlorid 
of  mercury,  arsenic,  nux  vomica,  and  nitroglycerin  are  of  value. 
The  tendency  toward  atonic  dyspepsia,  flatulency,  and  constipa- 
tion in  the  aged  should  be  avoided  by  the  use  of  appropriate 
drugs  and  other  therapeutic  measures.  The  possibility  of 
uncorrected  presbyopia  as  a  cause  in  these  cases  should  be 
remembered. 

In  all  varieties  of  vertigo,  the  patient  should  abstain  from  tea, 
coffee,  tobacco,  highly  seasoned  foods,  malt  liquors,  and  alcohol, 
unless  especially  indicated. 

MIGRAINE. 

Synonyms. — Megrim;  hemicrania;  sick  headache ;  bilious  head- 
ache. 

Definition. — A  unilateral  paroxysmal  pain  in  the  head,  accom- 
panied by  nausea,  often  vomiting,  intolerance  of  light  and  sound 
and  incapability  of  mental  exertion,  the  brain  being  temporarily 
prostrated  and  disturbed. 

Causes. — In  the  majority  of  patients,  the  nervous  predis- 
position to  migraine  is  inherited,  but  whether  inherited  or 
acquired,  it  commonly  develops  about  puberty.  It  is  more 
common  in  women  than  in  men. 

Among  the  many  exciting  causes  are  disturbances  of  digestion, 
irritation  of  the  ovaries  or  uterus,  worry,  anemia,  exacting 
m_ental  labor,  sexual  excesses  and  insufficient  sleep,  and  eye- 
strain. The  causes  of  many  attacks,  however,  are  wrapped  in 
mystery,  as  with  the  best  of  care  the  attacks  seem  to  have  a 
periodic  course. 

Symptoms. — Attacks  of  migraine  occur  in  irregular  paroxysms, 
the  intervals  between  being  free  from  pain  or  nervous  disturb- 
ance. For  a  day  or  two  preceding  the  paroxysm  it  may  be 
ascertained  that  there  were  feelings  of  fatigue  or  mental  de- 
pression without  apparent  cause,  heaviness  over  the  eyes, 
flatulency  and  indigestion. 

The  attack  proper  is  ushered  in  by  chilliness,  yawning,  nausea, 
often  vomiting,  and  general  muscular  soreness,  with  intolerance 


620  MIGRAINE. 

of  light,  flashes  before  the  eyes,  often  phantasms,  noises  in  the 
ears,  incapability  for  mental  exertion,  vertigo,  and  pain  of  a 
sharp,  shooting  character,  of  great  intensity  and  persistency, 
localized  most  frequently  in  either  the  frontal,  temporal,  or 
occipital  regions  of  the  left  side;  at  the  same  time  there  is  ten- 
derness over  the  whole  side  of  the  head.  Rarely  the  pain  is  felt 
on  the  right  side,  and  still  more  rarely  on  both  sides  at  the  same 
time.  The  nausea  and  other  digestive  symptoms  may  follow 
the  onset  of  the  pain  instead  of  preceding  it. 

There  is  more  or  less  disturbance  of  the  circulation,  tempera- 
ture, and  secretions  of  the  painful  parts.  At  times  there  is  a 
marked  contraction  of  the  vessels,  with  the  face  pale,  the  eyes 
shrunken,  and  the  pupils  dilated;  again,  the  vessels  may  be  di- 
lated, when  the  face  is  flushed,  the  conjunctivas  injected,  and 
the  pupils  contracted.  Motion,  sound,  and  light  aggravate  the 
acute  suffering.  The  urine  before,  during,  and  after  a  paroxysm 
is  concentrated,  and  it  may  be  that  the  excretion  of  uric  acid 
is  associated  with  the  etiology  of  migraine. 

The  attack  may  continue  with  more  or  less  intensity  from  a 
few  hours  to  two  or  three  days,  the  average  duration  being 
twenty-four  hours. 

Diagnosis. — The  symptoms  are  so  characteristic  that  an  error 
seems  impossible.  It  may,  however,  be  confounded  with 
anemic  headache,  hyperemic  headache,  dyspeptic  or  bilious 
headache,  and  neuralgic  or  rheumatic  headache.  The  pains  of 
organic  brain  disease  must  be  excluded. 

Prognosis. — While  few  cases  of  true  migraine  are  permanently 
cured,  the  affection  is  free  from  danger  to  life.  In  a  fair  number 
of  cases  the  susceptibility  to  attacks  declines  as  the  person  ad- 
vances in  years,  it  being  rarely  seen  after  fifty  years.  According 
to  Herter,  cases  of  migraine  of  the  ophthalmic  variety  appear  to 
be  not  rarely  followed  by  general  paralysis  of  the  insane..  When, 
however,  appropriate  treatment  is  instituted  in  cases  due  to 
eye-strain,  the  response  is  very  prompt  and  the  affection  dis- 
appears almost  immediately  and  does  not  recur. 

Treatment. — To  abort  an  attack  of  migraine,  or  to  dispel  a 
paroxysm  after  its  onset,  rest  in  bed  in  a  quiet  and  darkened 


MIGRAINE.  621 

room,  suitable  diet,  and  the  administrati(jn  ui  iTKjrjjhin  suljjhate, 
gr.  1/4  (0.016  gm.),  with  atropin  sulphate,  gr.  1/120  (0.00054  gm.), 
hypodermically,  antipyrin  gr.  xx  (1.3  gm.),  or  phenacetin, 
gr.  X  (0.6  gm.),  should  be  advised.  The  following  combination 
frequently  relieves  the  paroxysm: 

I^.     Phenacetin gr.  xx  i  .  3  gm. 

Caffein.  citrat gr.  v  .3  gm. 

Camphorae  monobrom. .  .    gr.  xx  i  .3  gm. 

M.     Ft.  capsule  No.  x. 
S. — One  every  two  hour.s  until  relief. 

In  many  attacks;  fluidextract  of  cannabis  indica,  n^^ii  to  iii 
(0.12  to  0.2  c.c),  every  half  hour  or  hour  for  a  number  of  doses, 
alone  or  combined  with  fluidextract  of  gelsemium,  in  the  same 
dose,  is  curative.  When  the  attacks  are  associated  with  con- 
traction of  the  vessels,  the  following  is  of  value: 

I^.      Potassii  bromid gr.  xxx  2 .          gm. 

Morphinae  sulph gr.  1/4  .016  gm. 

vel 

Codeinae  sulph gr-  j  .  065  gm. 

vel 

Tr.  opii  deodorat rr^xxx  2 .          c.c. 

Aquae  menth.  pip. q.  s.  ad  f5ss  ad  15.  c.c. 

M.  S. — One  dose.      To  be  repeated  as  the  occasion  requires. 

Locally,  the  application  of  menthol  pencils  to  the  seat  of  the 
pain  is  beneficial.  The  inhalation  of  spirits  of  camphor  may  at 
times  afford  relief. 

During  the  interval,  a  careful  investigation  should  be  made  to 
determine  the  underlying  cause,  and  its  removal  should  then  be 
accomplished.  As  most  individuals  possess  ametropia  in 
varying  degrees,  the  eye-strain  factor  in  the  etiology  should  be 
immediately  eliminated  by  proper  examination  of  the  eyes  under 
cycloplegia  and  the  prescribing  of  correcting  lenses  in  all  cases. 
Frequently  this  will  be  sufficient.  It  may  be  added,  that  not 
uncommonly  the  instillation  of  a  cyclopegic,  such  as  homatropin 
or  atropin,  will  relieve  an  attack.  Such  drugs  are  contrain- 
dicated  if  presbyopia  is  present,  but  it  should  also  be  remem- 


62  2  ACUTE   HYDROCEPHALUS. 

bered  that  migraine  is  rather  infrequent  in  persons  past  forty- 
five  years  of  age. 

The  gastrointestinal  tract  is  responsible  for  a  large  number 
of  cases  and  quite  often  the  individual  paroxysms  may  be  traced 
directly  to  some  dietetic  indiscretion.  Such  cases  require  care- 
ful regulation  of  the  diet,  eliminating  substances  which  are 
known  to  disagree  with  the  patient.  The  use  of  tea,  coffee, 
alcohol,  and  tobacco  should  be  reduced  to  a  minimum.  Con- 
stipation should  always  be  avoided.  In  all  cases,  extract  of 
cannabis  indica,  gr.  1/4  (0.016  gm.),  three  times  daily  for 
several  months  is  of  value. 

When  there  is  any  apparent  anemia,  tonics  such  as  iron,  quinin, 
strychnin,  and  arsenic  should  be  prescribed  together  with  good 
food,  fresh  air,  and  regulated  exercise. 

ACUTE  HYDROCEPHALUS. 

Synonyms. — -Acquired  hydrocephalus;  serous  apoplexy. 

Definition. — Strictly  speaking,  hydrocephalus  signifies  water 
in  the  brain,  but  it  is  here  restricted  to  the  presence  of  a  serous 
fluid  in  the  arachnoid  spaces,  in  the  pia  mater,  in  the  ventricles, 
amd  in  the  brain  substance  (edema) ;  characterized  by  the  more 
or  less  sudden  development  of  cerebral  excitation,  followed  by 
depression  and  usually  death. 

Causes. — The  affection  is  most  common  between  the  ages  of 
one  and  five  although  it  may  occur  at  any  age.  A  neurotic 
temperament  is  a  rather  strong  predisposing  factor.  Among 
the  exciting  causes  are  unfavorable  hygienic  conditions,  denti- 
tion, eruptive  fevers,  blows  on  the  head,  mechanical  causes 
preventing  the  return  of  the  blood  from  the  veins  of  Galen  and 
the  right  lateral  sinus,  compression  of  the  jugular  vein,  acute 
leptomeningitis,  diseases  of  the  right  heart,  and  Bright's  disease. 

Pathologic  Anatomy. — The  effusion  may  be  limited  to  the 
ventricles,  although  there  is  usually  considerable  distention  of 
the  subarachnoid  spaces  and  edema  of  the  pia  mater  and  neigh- 
boring portions  of  the  brain,  whence  results  more  or  less  soften- 
ing, especially  around  the  ventricles.  The  choroid  plexus  is 
hyperemic  and  may  be  the  seat  of  minute  extravasations. 


CONGENITAL   HYDROCEPHALUS.  623 

Symptoms. — According  to  the  grouping  of  the  principal  symp- 
toms, acute  hydrocephalus  may  be  considered  as  of  three  varie- 
ties, simple,  convulsive,  and  comatose. 

Simple  acute  hydrocephalus  is  most  common  in  children,  and 
begins  with  feverishness,  headache,  vertigo,  photophobia,  rest- 
lessness, nocturnal  delirium,  insomnia,  twitching,  spasmodic 
contractions  of  the  muscles,  and  great  hyperesthesia  of  the  skin. 
Such  symptoms  continue  for  several  days,  when  convulsions 
occur,  followed  by  death  or  a  continuance  of  the  symptoms, 
followed  by  rigidit}^,  stupor,  and  death. 

Convulsive  variety,  usually  the  result  of  Bright' s  disease  or  a 
general  dropsy,  is  ushered  in  with  headache,  nausea,  and  vomit- 
ing, followed  in  a  day  or  two  by  convulsions,  passing  into  coma, 
which  usually  terminates  fatally,  although  rarely  a  remission 
may  precede  death  for  a  day  or  two. 

Comatose  variety,  known  also  as  "serous  apoplexy,"  begins 
abruptly  with  the  phenomena  of  apoplexy,  the  result  of  the 
sudden  effusion.  The  pressure  is  usually  so  great  on  the  medulla 
oblongata  that  it  ceases  to  functionate,  death  resulting  usually 
in  a  few  hours,  rarely  several  days. 

Prognosis. — Unfavorable . 

Treatment. — The  underlying  disease  should  receive  careful  at- 
tention and  the  symptoms  should  be  relieved  as  they  arise.  An 
attempt  may  be  made  to  remove  the  fluid  by  diuretics  and  full 
doses  of  potassium  iodid. 

CONGENITAL  HYDROCEPHALUS. 

Synonym. — Chronic  hydrocephalus. 

Definition. — An  excessive  accumulation  of  the  cerebrospinal 
fluid,  a  cerebral  dropsy;  in  the  ventricles,  internal  hydrocepha- 
lus, or  in  the  meshes  of  the  pia-arachnoid,  external  hydrocephalus, 
or  in  both,  mixed  hydrocephalus;  characterized  by  enlargement  of 
the  head  and  more  or  less  pronounced  nervous  phenomena. 

Causes. — It  is  a  disease  of  infants  and  young  children,  and  is 
developed  in  the  prenatal  period.  The  affection  occurs  usually 
in  the  offspring  of  tubercular,  scrofulous,  or  syphilitic  parents. 
It  may  arise  from  imperfect  or  arrested  development  of  the  brain 


624  CONGENITAL   HYDROCEPHALUS. 

or  its  membranes  and  from  inflammatory  changes  in  the  ventri- 
cles and  ependyma.  Occlusion  of  the  passages  by  which  the 
ventricles,  and  ventricles  and  subarachnoid  space  communicate 
is  a  cause  in  many  cases. 

Pathologic  Anatomy. — Enlargement  of  the  head  is  the  chief 
external  manifestation,  but  there  is  no  constant  ratio  between 
the  size  of  the  head  and  the  amount  of  fluid,  the  quantity 
varying  from  an  ounce  to  a  pint  or  more.  The  liquid  is  trans- 
parent, of  a  straw  color,  containing  a  small  amount  of  albumin 
and  chlorid  of  sodium.  If  the  quantity  of  fluid  be  small,  the 
ventricles  are  simply  distended;  if  the  amount  be  large,  the  optic 
thalami  and  corpus  striatum  are  depressed  and  flattened,  the 
roof  of  the  ventricles  thinned,  and  the  foramen  of  Monro  is 
greatly  enlarged.  The  enlargement  of  the  head  may  occur 
before  birth  and  impede  or  prevent  natural  delivery,  or  the 
head  may  be  normal  at  birth  and  increase  afterward.  As  en- 
largement progresses,  the  bones  are  so  thinned  as  to  be  translu- 
cent; the  fontanelles  and  sutures  are  widened;  the  lateral  por- 
tions of  the  cranium  project;  the  forehead  bulges  out  over  the 
eyes;  and  the  orbital  plates  are  depressed,  forcing  the  eyes  out- 
ward and  downward,  producing  a  variety  of  exophthalmos;  and 
the  head  has  an  irregular,  triangular  shape,  the  base  of  the 
triangle  being  the  top  of  the  head.  The  scalp  being  stretched 
by  the  pressure  within,  becomes  tense  and  thin,  and  scantily 
covered  with  hair;  the  veins,  which  ramify  in  it,  are  usually 
prominent  and  large,  and  the  entire  head  is  elastic  on  pressure, 
from  the  amount  of  liquid  beneath. 

Hilton  believed  that  the  accumulation  of  fluid  constituting 
this  disease  was  due  entirely  to  an  obstruction  in  the  opening 
between  the  fourth  ventricle  and  the  spinal  canal. 

Symptoms. — The  flrst  manifestation  of  the  disease  to  attract 
attention  is  the  increased  size  of  the  head  in  an  emaciated  child 
whose  appetite  is  good  and  who  seemingly  partakes  of  food  well. 
The  head  appears  too  heavy;  the  eyes  are  prominent  and  have  a 
downward  direction;  the  face  is  devoid  of  expression,  old  and 
wrinkled,  the  voice  feeble;  and  the  mental  development  is  not 
in  keeping  with  the  age.      When  the  period  for  standing  or  walk- 


SPINAL   HYPEREMIA.  625 

ing  arrives,  the  power  is  found  wanting.  The  further  history 
is  but  a  continuation  and  exaggeration  of  this  state,  until  con- 
vulsions occur,  which  sooner  or  later  terminate  fatally.  The 
course  of  congenital  hydrocephalus  is  usually  slow,  but  becomes 
progressively  worse.  The  majority  terminate  within  the  first 
year;  cases  are  recorded,  however,  of  ten  and  fifteen  years' 
duration. 

Diagnosis. — -In  rachitis  the  volume  of  the  head  is  increased, 
due,  in  part,  at  least,  to  a  deposit  of  calcareous  matter  on  the 
exterior  of  the  cranial  bones.  Rachitis  may  be  mistaken  for 
hydrocephalus  in  cases  in  which  the  amount  of  liquid  is  small. 
The  differential  diagnosis  is  based  on  the  shape  of  the  head — 
round  in  rachitis,  square  or  triangular  or  with  prominences  in 
hydrocephalus,  with  the  persistent  downward  direction  of  the 
eyes  and  the  elasticity  of  the  head  on  pressure. 

Prognosis. — Unfavorable.  Arrest  of  progress  and  even  cures 
have  been  reported.  Spontaneous  cures  have  been  reported  fol- 
lowing the  accidental  discharge  of  the  fluid,  but  such  reports  are 
exceptional. 

Treatment. — The  use  of  the  finest  aspirator  needle  to  evacuate 
the  fluid  is  fully  justifiable.  The  proper  situation  for  the  punc- 
ture is  the  coronal  suture,  about  i  or  i  1/2  inches  from  the  anter- 
ior fontanelle.  Firm  but  gentle  compression  of  the  cranium 
with  adhesive  strips  should  be  made  during  the  escape  of  the 
fluid  and  afterward.  A  few  ounces  of  fluid  only  should  be 
withdrawn  at  a  time.  The  internal  use  of  potassium  iodid  is 
recommended.  All  measures  which  tend  to  promote  constructive 
metamorphosis  are  to  be  employed. 

DISEASES  OF  THE  SPINAL  CORD. 
SPINAL  HYPEREMIA. 

Synonym. — Spinal  congestion. 

Definition. — An  abnormal  fullness  of  the  vessels  of  the  men- 
inges and  cord;  active  when  an  arterial  hyperemia;  passive 
when  a  venous  hyperemia;  characterized  by  a  pain  in  the 
40 


626  SPINAL  HYPEREMIA. 

back,  with  more  or  less  pronounced  disorders  of  sensation  and 
locomotion. 

Causes. — Cold  and  exposure;  arrested  menses;  arrest  of  a 
habitual  hemorrhoidal  discharge;  malaria;  protracted  erect- 
posture;  injuries  to  the  back;  certain  spinal  poisons,  as  strych- 
nin, picrotoxin,  and  alcoholic  excesses. 

Pathologic  Anatomy. — Active.  The  post-mortem  appearances 
are  congestion  of  the  meninges  and  cord,  the  same  vessels  sup- 
plying both,  with  numerous  points  of  extravasation,  due  to 
the  rupture  of  capillary  vessels.  The  spinal  fluid  is  increased  in 
amount. 

Passive.  A  general  bluish  discoloration,  owing  to  the  abnor- 
mal fullness  of  the  large  anastomosing  vessels;  the  spinal  fluid  is 
somewhat  increased. 

Symptoms. — Active  hyperemia  is  manifested  by  dull  pain  in 
the  dorsal  or  lumbar  region,  shooting  into  the  hips  and  thighs, 
persistent  and  increased  by  pressure;  tenderness  on  motion; 
tingling  sensations  in  the  limbs  and  feet,  and  sometimes  in  the 
hands  and  arms;  a  feeling  of  constriction  about  the  abdomen  is 
often  present,  with  rigidity  of  the  abdominal  muscles;  increased 
reflexes,  with  disorders  of  motility,  and  when  the  patient  is  in 
the  recumbent  position,  jerking  of  the  limbs.  Walking  is  ac- 
complished with  difficulty,  from  an  incomplete  loss  of  power. 
If  the  upper  part  of  the  cord  be  affected,  dyspnea  and  palpita- 
tion will  occur.  There  may  also  occur  painful  priapism  and 
frequent  nocturnal  endssions. 

The  above  symptoms  may  be  followed  by  a  more  or  less  pro- 
nounced temporary  depression,  the  sensation  diminished,  and 
the  lower  limbs  benumbed  and  heavy,  the  movements  being 
weak.  The  electro-contractility  is  preserved,  and  in  many 
cases  even  increased  or  exaggerated. 

Duration. — The  affection  lasts  from  a  few  hours  to  several 
days,    and    when    unduly    prolonged    terminates    in    myelitis. 

Diagnosis. — Anemia  causes  more  or  less  spinal  irritabilit}^ 
and  tenderness;  but  the  history,  pallor,  and  general  weakness, 
unassociated  with  defects  of  motility  or  sensibility,  will  prevent 
error. 


SPINAL   PACHYMENINGITIS.  627 

Spinal  meningeal  hemorrhage  is  more  sudden  in  its  onset,  is 
more  violent,  and  has  a  greater  range  of  symptoms  than  spinal 
hyperemia. 

Myelitis  and  spinal  meningitis  have  symptoms  in  common 
with  spinal  congestion,  which  will  be  pointed  out  when  discuss- 
ing those  conditions. 

Prognosis. — The  outlook  is  favorable,  recovery  usually  taking 
place  in  three  or  four  days.  If  the  symptoms  show  a  tendency 
to   linger,    myelitis,  more  or  less  pronounced,  will  ensue. 

Treatment. — Rest  is  indicated,  but  the  patient  should  avoid 
lying  on  the  back.  Cups  or  leeches  should  be  applied  along  the 
spine  followed  either  by  the  iced  or  the  hot  douche  or  hot 
sponges.  Active  purgation  should  be  brought  about  to  lessen 
the  blood  pressure.  When  the  condition  is  due  to  arrested 
perspiration  a  hot-air  bath  and  the  administration  of  pilocarpin 
are  of  value.  When  it  follows  arrest  of  the  menses,  aconite 
will  be  of  benefit.  If  associated  with  a  very  active  circulation, 
potassium  bromid,  fiuidextract  of  gelsemium,  n^v  (0.3  c.c),  or 
fiuidextract  of  ergot,  f  5ss  to  i  (2  to  4  c.c),  will  afford  great 
relief. 

In  passive  hyperemia  the  cause  should  be  ascertained  and 
removed.  Ergot,  digitalis,  tonics,  and  purgatives  will  serve 
to  lessen  the  congestion. 


SPINAL  PACHYMENINGITIS. 

Synonyms. — Pachmeningitis  spinalis  interna;  hypertrophic 
pachymeningitis;  pseudo-membranous  pachymeningitis. 

Definition. — An  inflammation  of  the  inner  surface  of  the 
spinal  dura  mater  characterized  by  an  exudation  upon  this  inner 
surface,  attended  by  violent  pains  in  the  head,  neck,  shoulders, 
and  arms,  followed  by  muscular  contractures  and  paralyses  of 
the  upper  extremities. 

Causes. — Exposure  to  cold  and  damp,  alcoholism,  syphilis, 
gout,  and  injuries  are  most  common  causes.  It  may  be  second- 
ary to  Pott's  disease. 


628  SPINAL   PACHYMENINGITIS. 

Pathologic  Anatomy. — Hypertrophic  pachymeningitis  is  char- 
acterized by  an  exudation  upon  the  inner  surface  of  the  spinal 
dura  mater,  which  gradually  solidifies  into  a  layer  of  compact 
connective  tissue.  This  membrane  presses  upon  the  spinal 
cord  and  nerves  producing  myelitis  and  neuritis  with  subsequent 
muscular  atrophy.  The  most  frequent  seat  of  this  form  of  the 
affection  is  the  cervical  region  and  it  is  then  termed  cervical 
hypertrophic  pachymeningitis . 

In  the  pseudo-fnembranous  variety,  an  exudation  also  forms  in 
which  large  numbers  of  blood-vessels  develop  and  rupture,  the 
resulting  extravasation  forming  a  cyst  or  hematoma  which 
exerts  considerable  pressure  on  the  cord  and  nerves. 

Symptoms. — The  onset  is  slow  and  gradual,  with  irregular 
chills  and  feverishness,  more  or  less  continuous  violent  pains 
with  stiffness  in  the  head,  neck,  shoulders,  and  arms,  and  a 
painful  sense  of  constriction  of  the  upper  thorax.  Numbness 
and  pricking  in  the  arms  are  often  present.  Occasionally 
nausea  and  vomiting  occur.  These  symptoms  may  continue  in 
varying  degrees  of  severity  for  several  months,  the  muscles  of  the 
painful  parts  ultimately  undergoing  atrophy,  followed  by  spas- 
modic contraction,  particularly  of  the  hands  and  wrists,  and 
eventually  by  paralysis.  The  paralytic  stage  develops  gradually 
with  weakness  in  the  arms  associated  with  contractures  and  rigid- 
ity. The  pain  continues  and  there  may  be  anesthesia,  hyperes- 
thesia, or  paresthesia.  Trophic  changes  are  common.  Later, 
there  develop  paraplegia  with  rigidity,  exaggerated  reflexes 
and  spinal  epilepsy.  The  electro-contractility  is  lost.  It  has 
been  observed,  clinically,  that  the  immediate  cause  of  death  in 
chronic  cerebral  and  spinal  disease  is  to  be  found  in  an  intercur- 
rent attack  of  nephritis  or  tuberculosis. 

Prognosis. — If  early  recognized  and  promptly  treated,  the 
hypertrophic  form  may  be  improved.  Generally,  however, 
the  prognosis  is  unfavorable. 

Treatment. — Rest  in  bed  with  repeated  counterirritaion  over 
the  spine  is  indicated.  The  diet  should  be  highly  nutritious 
and  drugs  such  as  cod-liver  oil,  hypophosphites,  and  potassium 
iodid  should  be  administered.     The  various  symptoms,  such  as 


SPINAL   MENINGITIS.  629 

pains  and  spasms,  should  be  treated  as  they  arise  on  general 
principles. 

SPINAL  MENINGITIS. 

Synonym. — Spinal  leptomeningitis. 

Definition. — Inflammation  of  the  arachnoid  and  pia  mater 
membranes  of  the  spinal  cord,  either  acute,  subacute,  or  chronic; 
characterized  by  pain  in  the  back,  rigidity  of  the  muscles,  and 
disorders  of  motility  and   sensibility. 

Causes. — The  disease  is  rare  and  is  nearly  always  due  to  an 
infection.  Cerebrospinal  meningitis,  tuberculosis,  syphilis, 
typhoid  fever,  septicemia,  traumatism,  and  exposure  are  the 
most  common  causes. 

Pathologic  Anatomy. — The  acute  form  is  attended  by  hyper- 
emia of  the  membranes  with  swelling  of  the  tissues,  the  result 
of  serous  infiltration,  followed  by  purulent  and  fibrinous  exuda- 
tions. The  roots  of  the  spinal  nerves  are  covered  with  exuda- 
tion, and  are  swollen  and  soft.  The  cord  proper  is  more  or 
less  congested  and  edematous. 

In  the  chronic  form,  there  is  adhesion  of  the  membranes,  with 
more  or  less  accumulation  of  fluid,  resulting  in  atrophic  degen- 
eration of  the  cord  from  pressure.  When  the  disease  is  tuber- 
culous in  origin,  granulations  are  seen  distributed  over  the  pia, 
arachnoid,  and  inner  surface  of  the  dura. 

Symptoms. — There  are  two  stages:  the  first,  the  stage  of  irrita- 
tion; the  second,  the  stage  of  paralysis  of  motion  and  sensation, 
with  atrophy.  Although  an  inflammatory  affection,  its  onset  is 
usuall}^  subacute,  the  febrile  reaction  being  moderate,  with 
intense  boring  pain  in  the  back,  aggravated  by  motion,  rigidity 
of  the  spine,  and  a  sense  of  constriction  around  the  body — 
"the  girdle."  Spasmodic  contractions  of  the  muscles  supplied 
by  the  nerves  originating  at  the  seat  of  the  lesion,  with  inability 
to  straighten  the  limbs  are  also  present.  If  the  lower  part  of 
the  spinal  membranes  is  the  seat,  there  occur  retention  of  urine 
and  constipation;  if  upper  part,  dysphagia,  dyspnea,  and  feeble 
heart.     If  the  inflammation  extend  to  the  medulla,  the  above 


630  SPINAL   MENINGITIS. 

symptoms  are  associated  with  disorders  of  speech,  vomiting, 
and  delirium.  The  musciilar  contractions  are  excited  or  in- 
creased by  motion,  but  uninfluenced  by  pressure.  Reflex 
movements  are  not  abolished.  The  rigidity  and  spasmodic 
contractions  of  the  muscles  are  followed  by  paralysis,  more  or 
less  complete,  death  ensuing  from  paralysis  of  the  muscles  of 
respiration. 

Electro-contractility  is  lessened  or  absent,  both  as  to  motility 
and  sensibility  in  the  affected  parts. 

The  chronic  form  succeeds  to  the  acute  or  originates  spontane- 
ously, and  presents  the  same  form  and  order  of  symptoms — 
excitation  or  irritation,  and  depression  or  paralysis. 

Diagnosis. — The  points  of  importance  are:  deep,  boring  pain 
in  the  back,  aggravated  by  motion  but  not  by  pressure,  with 
spasmodic  contraction  of  the  muscles,  followed  by  paralysis. 

Myelitis  is  marked  by  slight,  or  no  pain,  with  earlier  and  more 
complete  paralysis. 

Tetanus  may  be  confounded  with  spinal  meningitis.  The 
points  of  distinction  are :  in  the  former  occur  early  trismus  with 
rhythmic  spasms  excited  by  irritation  of  the  skin,  whereas 
irritation  of  the  skin  does  not,  in  spinal  meningitis,  produce 
muscular  contractions,  but  movement  of  the  limbs  does;  tetanus 
progressively  increases,  and  is  not  associated  with  fever;  there 
is  usually  a  clear  history  of  an  injury. 

Prognosis. — Generally  unfavorable.  Death  is  either  sudden, 
from  paralysis  of  respiration  and  of  the  heart,  or  gradually,  the 
restdt  of  exhaustion. 

Critical  discharge  ,  such  as  profuse  perspiration,  urinary  flow, 
or  epistaxis  occasionally  occur,  and  are  followed  by  rapid  recov- 
ery. Cases  recovering  may  have  more  or  less  pronounced 
partial  or  complete  paralysis. 

Treatment. — The  patient  should  be  placed  at  rest  in  bed  and 
allowed  to  lie  on  the  side  or  face.  Cups  or  leeches  should  be 
applied  along  the  spine,  followed  by  ice,  the  hot  douche,  hot 
sponges,  or  mustard.  Free  purgation  should  be  obtained.  In 
cases  due  to  syphilis,  mercury  and  the  iodids  should  be  given  in 
full  doses.     In  the  paralytic  stage,  quinin  sulphate,  gr.  iii  (0.2 


ACUTE    MYELITIS.  63 1 

gm.),  with  alcoholic  extract  of  belladonna,  gr.  1/4  (0.016  gm.), 
three  times  daily,  is  often  of  great  value.  The  galvanic  current 
should  be  applied  to  the  spine  and  to  the  nerve  trunks  and  the 
faradic  current  to  the  affected  muscles.  Deep  injections  of 
strychnin  and  massage  should  also  be  employed. 


ACUTE  MYELITIS. 

Synonyms. — Acute  or  general  diffuse  myelitis;  transverse 
myelitis;  softening  of  the  cord. 

Definition. — An  inflammation  affecting  the  substance  of  the 
spinal  cord,  which  may  be  limited  to  the  gray  or  white  matter, 
and  may  involve  the  whole  or  isolated  portions  of  the  cord. 
When  the  gray  matter  alone  is  inflamed,  it  is  termed  central 
myelitis;  when  the  white  matter  and  the  meninges,  it  is  termed 
cortical  myelitis;  it  may  be  ascending,  descending,  or  transverse 
in  its  extension.  The  disease  is  characterized  by  more  or  less 
sudden  and  complete  loss  of  motion  and  sensation. 

Causes. — It  may  follow  acute  congestion  or  spinal  meningitis, 
or  it  may  be  due  to  exposure  to  cold  and  damp  or  wet  weather, 
injuries  to  the  vertebrae,  syphilis,  rheumatism,  puerperal  fever, 
typhus  fever,  exanthemata,  or  to  poisoning  by  lead,  arsenic,  or 
mercury. 

Pathologic  Anatomy. — The  substance  of  the  cord  is  intensely 
hyperemic  and  extravasations  are  scattered  throughout  it  giving 
to  the  tissues  a  reddish  brown  or  chocolate  tint.  Sometimes 
prominent  hemorrhagic  effusions  are  observed.  Serous  trans- 
udations are  also  present  resulting  in  softening  of  the  structure 
of  the  cord,  the  color  changing  to  yellow  and  white;  the  nerve - 
elements  undergo  fatty  degeneration  and  present  the  appear- 
ance and  consistency  of  cream.  The  membranes  are  involved 
in  more  or  less  similar  changes.  The  microscope  reveals  degen- 
eration of  the  cellular  elements  and  their  replacement  by  fat 
granules,  granular  debris,  and  blood  cells. 

Symptoms. — The  severity  of  the  symptoms  depends  upon  the 
extent  and  location  of  the  inflammation. 


632  ACUTE   MYELITIS. 

The  onset  is  usually  sudden,  with  a  chill,  fever,  103°  F.,  fre- 
quent pulse,  and  alterations  in  sensibility  and  motility — viz., 
pain  in  the  back,  aggravated  by  touch  and  by  heat  and  cold, 
with  sensations  of  formication  ("pins  and  needles"),  the  limb 
feeling  as  if  asleep,  or  complete  anesthesia,  associated  with 
severe  neuralgic  pains.  The  sensation  of  constriction  around 
the  body  and  limbs,  as  if  encircled  by  a  tight  cord,  "  the  girdle 
pains,"  is  a  characteristic  symptom,  and  is  followed  by  a  rapidly 
developing  paraplegia  which  becomes  complete  in  a  few  hours 
and  is  accompanied  by  involuntary  discharges.  The  reflex 
functions  are  usually  abolished,  as  seen  by  attempting  to  cause 
movement  of  the  limbs  by  tickling  the  feet  or  by  striking  the 
patella  tendon;  rarely  are  they  diminished,  very  rarely  exag- 
gerated. The  temperature  of  the  affected  limbs  is  lowered 
three  or  four  degrees.  Sloughs  and  bed-sores,  and  muscular 
atrophy  result  if  the  anterior  cornua — the  trophic  centers — are 
affected. 

The  symptoms  of  loss  of  motion  and  sensibility,  with  rectal 
and  vesical  paralysis,  are  associated  with  more  or  less  pro- 
nounced vomiting,  hepatic  disorders,  irregularity  of  the  heart, 
dyspnea,  dysphagia,  apnea,  and  painful  priapism.  The  urine 
is  markedy  alkaline  in  reaction,  finally  developing  cystitis. 
Among  the  late  manifestations  are  shooting  pains  and  spas- 
modic twitchings  or  contractions  of  one  or  all  of  the  muscles  of 
the  paralyzed  parts.  The  electro-contractility  is  abolished  in 
the  paralyzed  parts. 

Diagnosis. — The  principal  diagnostic  features  of  acute  mye- 
litis are  the  "girdle"  around  the  limbs  or  body,  rapid  and  com- 
plete paraplegia,  loss  of  sensation,  lowered  temperature  in  the 
affected  parts,  early  and  persistent  sloughing  (bed-sores),  and 
alkaline  urine  or  cystitis. 

The  diagnosis  of  the  location  of  the  lesion  is  made  by  a  study 
of  the  degree  of  the  anesthesia,  the  skin  reflexes,  and  the  distri- 
bution and  extent  of  the  paralysis,  which  are  shown  in  the  fol- 
lowing table  from  Dana: 


ACUTE    MYELITIS. 


^3:^ 


Localization    of  the  Functions  of  the  Segments  of  the 

vSpinal  Cord. 


Segment. 


Muscles. 


Reflex  and  centers. 


Sensation. 


First  cervical Rectus  lateralis. 

Rectus  capitis. 
I   Anticus  and   posti- 
1      cus. 

Sterno-hyoid. 

Sterno-thyroid. 

Sterno-mastoid. 

Trapezius. 

Scaleni  and  neck. 

Omo-hyoid. 

Diaphragm. 


Second    and    third 
cervical. 


Sixth  cervical 


Fourth  cervical .  .  .     Diaphragm. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Supinator-longus. 

Rhomboid. 

Supra-    and    infra- 
spinatus. 

Deltoid. 
Fifth  cervical Biceps. 

Coraco-brachialis. 

Brachialis  anticus. 
]   Supinator-longus. 

Supinator-brevis. 

Deep     muscles     of 
shoulder-blade. 

Rhomboid. 

Teres  minor. 

Pectoralis   (clavicu- 
lar part). 

Serratus  magnus. 

Deltoid. 

Biceps, 
part) . 

Pectoralis   (clavicu- 
lar). 

Serratus  magnus. 

Triceps. 

Pronators. 

Brachialis  anticus. 

Subscapular. 

Rhomboid. 

Latissimus  doisi. 

Triceps  (longhead). 

Extensors   of   wrist 
and  fingers. 

Pronators  of  wrist. 

Flexors  of  wrist. 

Subscapular. 

Pectoralis  (costal). 


Latissimus  dorsi. 
Teres  major. 

Triceps  (long  head) 
Flexors  of  wrist  and 
fingers. 

Intrinsic  hand  mus- 
cles. 


Seventh  cervical. 


Eighth  cervical. 


Hypochondrium  ( ? ) . 
Sudden  inspiration 
produced  by  sudden 
pressure  beneath  the 
lower  border  of  ribs. 


Pupillary  (fourth  cer- 
vical to  second  dor- 
sal). Dilatation  of 
the  pupil  produced 
by  irritation  of  neck. 


Scapular  (fifth  cervi- 
cal to  first  dorsal). 
Irritation  of  skin 
over  the  scapula  pro- 
duces contraction  of 
scapular  muscles. 

Supinator  long  us. 
Tapping  the  tendon 
of  the  supinator 
longus  produces  flex-j 
ion  of  forearm.  I 


Triceps  (fifth  to  sixth 
cervical) .  Tapping 
elbow  tendon  pro- 
duces extension  of 
forearm. 

Posterior  wrist  (sixth 
to  eighth  cervical) . 
Tapping  tendons 
causes  extension  of| 
hand.  | 


Anterior  wrist  (sev- 
enth to  eighth  cer- 
vical). T  a  p  p  i  ng: 
anterior  tendons 
causes  flexion  of 
wrist. 

Palmar  (seventh  cer- 
vical to  first  dorsal).  | 
Stroking  palm! 
causes  closure  of 
fingers. 


Back  of  head  to  ver- 
tex and  neck  (oc- 
cipitalis major,  oc- 
cipitalis minor,  au- 
ricularis  magnus, 
superficialis  colli, 
and  supraclavicular) . 

Neck. 

Shoulder,  anterior 
surface. 

Outer  arm  (supra- 
clavicular, circum- 
flex, external  mus- 
culo-cutaneous,  cu- 
taneous) . 

Back  of  shoulder  and 
arm. 

Outer  side  of  arm  and 
forearm  to  the  wrist 
(supraclavicular,  cir- 
cumflex, external 
cutaneous,  internal 
cutaneous,  posterior 
spinal  branches). 


Outer  side  and  front 

of  forearm. 
Back  of  hand,  radial 

distribution. 
(Chiefly      external 

cutaneous,     internal 

cutaneous,  radial.) 


Radial  distribution  in 
the  hand. 

Median  distribution 
in  the  palm,  thumb, 
index,  and  one-half 
middle  finger. 
(External  cutaneous, 
internal  cutaneous, 
radial,  median,  pos- 
terior  spinal 
branches.) 

Ulnar  area  of  hand, 
back  and  palm,  inner 
border  of  forearm 
(internal  cutaneous 
ulnar) . 


634 


ACUTE   MYELITIS. 


Localization   of   the  Functions  of  the  Segments  of  the 
Spinal  Cord. — Continued. 


Segment 


Muscles. 


Sensation. 


First  dorsaL 


Second  dorsal 


Second  to  twelfth 
dorsal. 


First  lumbar. 


Second  lumbar  .  .  . 


Third  lumbar. . 
Fourth  lumbar. 


Fifth  lumbar 


First    and 
sacral. 


second 


Third,  fourth,  and 
fifth  sacral. 


Extensors  of  thumb 
Intrinsic  hand  mus 

cles. 
Thenar   and   hypo- 

thenar  muscles. 


Muscles  of  back  and 

abdomen. 
Erectores  spina?. 


None. 


Vastus  internus  . . 


Sartorius;      adduc- 
tors of  thigh. 
Flexors  of  thigh  .  . . 
Extensors  of  knee. 
Abductors  of  thigh. 


Outward  rotators. 
Flexors  of  knee. 
Flexors  of  ankle. 
Peronei. 
Extensors  of  toes. 


Calf  muscles. 

Glutei.  _ 

Peronei. 

Extensors  of  ankle. 

Small  muscles  of 
foot. 

Peronei. 

Muscles  of  bladder, 
rectum,  and  exter- 
nal genitals. 


Epigastric  (fourth  to 
seventh  dorsal) . 

Tickling  mammary 
region  causes  retrac- 
tion of  the  epigas- 
trium. 

Abdominal  (seventh 
to  eleventh  dorsal). 

Stroking  side  of  ab- 
domen causes  retrac- 
tion of  belly. 

Vasomotor  centers. 
Second  dorsal  to  sec- 
ond lumbar. 

Cremasteric  (first  to 
third  lumbar). 
Stroking  inner  thigh 
causes  retraction  of 
scrotura. 

Patellar.  Striking 

patellar  tendon 
causes  extension  of 
leg. 


Gluteal  (fourth  to 
fifth  lumbar).  Strok- 
ing buttock  causes 
dimpling  in  fold  of 
buttock. 

Achilles  tendon.  Over- 
extension causes 
rapid  flexion  of  an- 
kle, called  ankle 
clonus. 


Plantar  (fifth  lumbar 
to  second  sacral) . 
Tickling  sole  of  foot 
causes  flexion  of  toes 
and  retraction  of  leg. 


Genital  center. 
Vesical  center. 
Anal  center. 


Chiefly  inner  side  of 
forearm  and  arm  to 
near  the  axilla. 
(Chiefly  internal 
cutaneous  and  nerve 
of  Wrisberg  or  lesser 
internal   cutaneous.) 

Inner  side  of  arm  near 
and  in  axilla  (inter- 
costo-humeral) . 

Skin  of  chest  and  ab- 
domen, in  bands 
running  around  and 
downward  c  o  r  r  e- 
sponding  to  spinal 
nerves. 

Upper  gluteal  region 
(intercostals  and 

dorsal  posterior 

nerves) . 


Skin  over  groin  and 
front  of  scrotum 
(ilio-hy po  gastric, 
ilio-inguinal) . 

Outer  side  and  upper 
front  of  thigh.  Lum- 
bar region  (geni- 
to-crural,  external 
cutaneous). 

Front  and  outer  side 
of  thigh.  Inner  side 
of  leg  and  foot. 

Inner  side  of  thigh, 
leg,  and  foot  (inter- 
nal cutaneous,  long 
saphenous,  obturat- 
or). 

Back  of  thigh  and 
outer  side  of  leg  and 
ankle;  sole;  dorsum 
of  foot. 

(External  popliteal, 
external  saphenous, 
musculo  -  cutaneous, 
plantar). 

Back  of  buttock  and 
thigh;  side  of  leg 
and  ankle;  sole;  dor- 
sum of  foot. 


Circumanal  region , 
anus,  rectum,  penis, 
urethra,  vagina, 
perineum  (small 
sciatic,  pudic,  infer- 
ior hemorrhoidal,  in- 
ferior pudendal). 


ACUTE   MYELITIS.  635 

Acute  spinal  meningitis  is  distinguished  from  acute  myelitis  by 
severe  pains,  increased  by  pressure,  with  muscular  contractions 
increased  by  motion,  followed  by  paralysis  much  less  profound 
than  the  paraplegia  of  myelitis;  in  spinal  meningitis  there  exists 
cutaneous  and  muscular  hyperesthesia,  which  are  absent  in 
myelitis. 

Congestion  of  the  spinal  cord  is  characterized  by  the  mild 
character  and  short  duration  of  all  the  symptoms. 

Hemorrhage  in  the  spinal  cord  is  abrupt  with  irritative  symp- 
toms, slight  paralysis,  preserved  reflexes  and  electro-contractility. 

Hysteric  paraplegia  shows  no  trophic  changes,  no  altered  re- 
flexes, slight  atrophy,  irregular  anesthesia,  contractures  with  im- 
paired sensation  of  the  contracted  limb,  and  the  presence  of  the 
stigmata  of  hysteria. 

Lithemic  paresthesia,  characterized  by  tingling  and  numbness 
of  fingers  and  toes,  might  lead  to  error  if  the  cerebral  symptoms 
of  lithemia  are  overlooked. 

Prognosis. — This  depends  upon  the  location  of  the  lesion  and 
completeness  of  the  symptoms.  If  the  paralysis  is  of  the  as- 
cending variety,  death  occurs  within  a  few  days,  from  paralysis  of 
the  muscles  of  respiration.  If  the  trophic  centers  are  affected, 
there  occur  bed-sores,  intense  pyelo-nephritis  and  cystitis,  and 
changes  in  the  joints;  death  results  from  exhaustion  in  several 
weeks.  Central  myelitis,  or  inflammation  of  the  gray  matter,  is 
rapid  in  its  progress,  death  occurring  in  a  week  or  two.  The 
morbid  process  may  in  rare  instances  be  arrested  and  the  general 
health  restored,  but  some  spinal  symptoms  will  persist. 
•  Treatment. — Absolute  rest  is  essential  to  even  secure  a  pallia- 
tion of  the  symptoms. 

Locally,  considerable  relief  follows  the  use  of  hot  water  bags 
or  sponges  dipped  in  hot  water  and  applied  along  the  spine  every 
few  hours. 

Internally,  digitalis,  strychnin  stdphate,  ergot,  belladona,  bro- 
mids,  iodids,  cimicifuga,  quinin  sulphate,  and  other  similar  drugs 
may  be  employed  but  the  result  following  their  use  is  somewhat 
doubtful.  Careful  nursing  is,  however,  of  great  benefit.  Abso- 
lute cleanliness  and  frequent  change  of  posture  is  necessary  to 


636  INFANTILE    SPINAL   PARALYSIS. 

prevent  bed-sores.  Retention  of  urine  should  be  avoided  by 
frequent  aseptic  catheterization.  Cystitis  should  be  treated  by 
boric  acid  irrigations.  The  condition  of  the  intestinal  tract 
should  also  receive  attention.  If  the  affection  shows  any  tend- 
ency toward  recovery,  this  tendency  should  be  stimulated  by 
electricity  and  massage. 

INFANTILE  SPINAL  PARALYSIS. 

Synonyms. — Myelitis  of  the  anterior  horns;  acute  anterior 
poliomyelitis;  essential  paralysis  of  children;  atrophic  paralysis 
of  children;  infantile  palsy. 

Definition. — A  rapidly  developed  inflammation  of  the  ante- 
rior horns  of  the  gray  matter  of  the  cord,  occurring  suddenly  in 
children,  occasionally  in  adults — acute  spinal  paralysis  of 
adults — characterized  by  mild  fever,  muscular  tremors  and 
twitchings,  and  paralysis  of  groups  of  muscles,  followed  by  more 
or  less  atrophy. 

Causes. — It  is  essentially  a  disease  of  early  life,  from  the 
second  month  to  the  third  or  fourth  year,  but  it  may  rarely  be 
observed  in  adults.  The  affection  is  more  common  during  the 
summer  months,  and  males  are  most  often  attacked.  It  occa- 
sionally appears  in  epidemic  form.  The  real  cause  is  unknown. 
Exposure  to  cold  and  damp,  dentition,  injuries,  and  the  infec- 
tious fevers  may  act  as  predisposing  causes. 

Pathologic  Anatomy. — The  early  changes  are:  Medullary 
hyperemia,  vascular  exudation,  and  inflammatory  softening, 
although  the  naked  eye  may  not  recognize  any  changes.  Micro- 
scopic examination  reveals  inflammatory  softening  of  the  an- 
terior horns  of  the  gray  matter.  Among  other  constant  lesions 
are  atrophic  degeneration  of  the  multipolar  ganglion-cells  and 
of  the  anterior  nerve-roots.  The  changes  noted  as  occurring 
in  the  cord  are  usually  limited  to  the  dorso-lumbar  and  cervical 
enlargements. 

As  a  direct  result  of  the  changes  in  the  trophic  centers  and  the 
nerve  degeneration  of  the  muscular  fibers  supplied,  there  ensue 
changes  in  the  bones  and  joints,  leading  to  great  deformities. 


INFANTILE    SPINAL    PARALYSIS.  637 

Symptoms. — The  onset  of  the  affection  varies;  it  may  be  acute, 
subacute,  or  chronic;  it  is  usually  sudden,  with  an  attack  of  mild 
fever  of  a  remittent  type,  of  a  few  days'  duration,  on  recovery 
from  which  it  is  noticed  that  the  child  is  paralyzed.  Rarely,  the 
paralysis  may  be  preceded  by  convulsions. 

The  paralysis  may  affect  both  arms  and  both  legs,  the  legs 
alone,  or  only  one  of  the  four  extremities;  it  may,  very  rarely, 
be  a  hemiplegia.  As  a  rule,  however,  the  leg  suffers  more  fre- 
quently than  the  arm;  in  paralysis  of  the  leg  the  muscles  below 
the  knee  suffer  more  severely  than  those  above.  The  bladder 
and  rectum  are  not  affected,  or,  if  so,  only  temporarily,  and  an- 
esthesia or  numbness  cannot  be  detected.  The  temperature  of 
the  paralyzed  limb  is  low  and  the  part  is  cyanosed  in  appearance. 
After  a  few  days  there  is  a  slight  improvement  in  the  paralyzed 
parts,  although  the  muscles  show  a  rapid  wasting,  which  is  pro- 
gressive until  all  muscular  tissue  is  gone.  The  reflex  movements 
are  impaired  or  abolished. 

.  The  electro-contractility  by  the  faradic  current  is  abolished  in 
the  paralyzed  parts. 

With  the  galvanic  or  constant  current  the  "  reactions  of  degen- 
eration" are  developed.  To  fully  understand  the  meaning  of 
this  term  a  knowledge  of  the  normal  electrical  reactions  is 
necessary. 

(  The  normal  formulas  for  the  production  of  muscular  contrac- 
tion in  the  physiologic  state  are  as  follows,  the  strength  of  the 
current  being  barely  capable  of  causing  fair  contractions: 

1.  The  most  effective  contractions  are  produced  by  the 
cathode  (negative)  pole  on  closing  the  circuit  (C.   C). 

2.  The  second  most  effective  are  produced  by  the  anode 
(positive)  pole  on  closing  the  circuit  (A.  C). 

3.  The  next  most  effective  is  by  the  anode  pole  on  opening 
the  circuii  (A.  O.). 

4.  Cathode  pole  contractions  on  opening  circuit  are  rarely 
•seen  in  the  physiologic  state  (C.  O.). 

The  "reactions  of  degeneration"  are  shown  by  any  reversal 
of  the  regular  formulas;  so  that  if  the  anodal  closure  (A.  C.) 
shows  stronger  contractions  than  cathodal  closure  (  C.  C.) ;  still 


638  INFANTILE  SPINAL  PARALYSIS. 

greater  degeneration  is  shown  if  anodal  opening  (A.  O.)  contrac- 
tions are  stronger  than  either  of  the  above;  and  most  com- 
plete degeneration  is  shown  by  the  complete  reversal  of  the 
normal  formulas  as  shown  by  distinct  cathodal  opening  (C.  O.) 
contractions. 

Pathology  of  Reaction  of  Degeneration. — The  nerves  affected 
show:  (i)  Nuclei  swollen  and  granular,  (2)  the  white  sub- 
stance of  Schwann  is  broken  up,  (3)  the  axis  cylinders  are 
broken,  and  (4)  the  nerve  substance  becomes  a  fibrous  cord. 
The  muscles  show:  (i)  Great  increase  in  fibrous  tissue,  (2) 
presence  of  granules,  (3)  atrophy  of  muscular  fibers,  and  (4) 
disappearance  of  the  transverse  striae. 

Sequels. — Among  the  deformities  resulting  from  the  paralysis 
are  the  different  forms  of  talipes. 

Talipes  equinus,  the  result  of  paralysis  of  the  antero-extemal 
muscular  group  of  the  leg. 

Equino-varus,  the  result  of  paralysis  of  the  antero-extemal 
muscular  group  of  the  leg,  together  with  the  adductors  of  the 
foot. 

Talipes  calcaneus,  the  result  of  paralysis  of  the  muscles  of  the 
calf  of  the  leg. 

Talipes  cavus — "  pes  cavus" — characterized  by  the  hollow- 
ing of  the  sole  of  the  foot,  with  prominence  of  the  instep, 
the  result  of  paralysis  of  the  calf  muscles  with  contraction 
of  the  long  flexor  of  the  toe  or  the  long  peroneus — the  foot 
flexors. 

Diagnosis. — The  recognition  of  acute  poliomyelitis  is  not 
always  possible  at  the  onset  or  during  the  early  days  of  its  course, 
as  localized  paralyses  are  difficult  of  detection  in  children,  but 
immobility  of  one  leg  or  arm  in  children  with  febrile  symptoms, 
or  following  convulsions,  is  always  an  indication  of  poliomyelitis. 
After  the  initial  stage  has  passed,  the  presence  of  paralysis, 
wasting,  presence  of  R.  D.  (reactions  of  degeneration),  loss  of 
reflexes,  and  the  absence  of  anesthesia,  render  the  diagnosis ' 
very  easy. 

Hemiplegia  from  acute  cerebral  affections  in  children  can  be 
distinguished  from  infantile  paralysis  by  the  disorders  of  intelli- 


CHRONIC   PROGRESSIVE   BULBAR   PARALYSIS.  639 

gence  and  the  special  senses,  and  the  perseverance  of  the  normal 
electro-contractility. 

Paralysis  of  myelitis  occurs  in  older  persons,  and  is  associated 
with  disturbances  of  the  genitourinary  organs  and  bed-sores. 

Pseudo-muscular  hypertrophy,  with  paralysis,  begins  gradu- 
ally, becoming  progressively  worse  with  increase  in  the  size  of 
the  limbs. 

Prognosis. — Except  in  cases  in  which  the  onset  is  very  severe, 
the  outlook  as  regards  life  is  good.  More  or  less  paralysis  with 
muscular  wasting  and  deformities  always  results,  but  by  its 
early  recognition  and  prompt  treatment  the  extent  may  be 
greatly  lessened. 

Treatment. — During  the  febrile  stage  the  patient  should  be 
placed  at  rest  in  bed  and  all  the  secretions  rendered  free.  If  the 
affection  is  suspected  at  this  period,  the  limbs  should  be  wrapped 
in  cotton-wool  and  ergot  administered  to  lessen  the  spinal 
congestion.  Counterirritation  is  unnecessary.  As  soon  as  the 
febrile  reaction  has  subsided  and  the  paralysis  becomes  manifest 
the  child  should  be  well  fed  and  taken  out-doors  once  daily. 
Gentle  friction  should  be  applied  to  the  affected  muscles  at  first, 
followed  later  by  the  hot  spinal  douche  and  mild  galvanism. 
Internally,  quinin,  belladonna,  ergot,  and  potassium  iodid 
may  be  of  value.  Later,  as  improvement  takes  place  tincture 
of  nux  vomica,  nii  to  iii  (0.06  to  0.2  gm.),  three  times  daily,  or 
hypodermic  injections  of  strychnin  sulphate,  gr.  1/16  to  i/ioo 
(0.004  to  0.00065  g^"^-)-  according  to  the  age,  twice  a  week,  and 
faradism  to  the  paralyzed  muscles  are  to  be  used.  Means 
should  be  taken  to  prevent  deformities. 

CHRONIC   PROGRESSIVE   BULBAR  PARALYSIS. 

Synonyms. — Glosso-labio-laryngeal  paralysis;  bulbar  paral- 
ysis. 

Definition. — A  chronic  degenerative  affection  of  certain 
nuclei  of  the  medulla  oblongata,  characterized  by  a  slowly 
progressive  bilateral  paralysis  of  the  tongue,  lips,  palate,  pharynx, 
and  larynx,  with  atrophy  of  the  tongue  and  lips. 


640  CHRONIC    PROGRESSIVE    BULBAR    PARALYSIS. 

Causes. — The  etiology  is  obscure.  It  rarely  occurs  before  the 
fortieth  year.  It  may  be  brought  about  by  extension  of  spinal 
or  cerebral  affections  to  the  medulla.  Among  other  etiologic  in- 
fluences may  be  mentioned  cold,  rheumatism,  gout,  syphilis, 
and  injuries  about  the  neck. 

Pathologic  Anatomy. — The  structural  changes  consist  in 
degenerative  atrophy  of  the  gray  nuclei  in  the  floor  of  the  fourth 
ventricle,  with  atrophy  and  gray  discoloration  of  the  nerve-roots 
from  the  medulla,  especially  of  the  facial  and  hypoglossal  nerves. 
The  motor  ganglion-cells  atrophy  and  disappear,  not  infre- 
quently being  the  only  changes.  The  nerves  supplied  to  the 
muscles  exhibit  sclerosis  of  the  neurilemma,  and  degenerative 
atrophy  is  found  in  the  nerve-roots  coming  from  the  bulb. 

Symptoms. — The  disease  begins  insidiously.  There  is  first 
noticed  some  difficulty  in  articulation,  from  want  of  precision  in 
movements  of  the  tongue,  particularly  in  the  use  of  the  lingual 
consonants,  /,  n,  r,  and  t,  which  increases  until  that  organ  is 
completely  paralyzed.  The  paralysis  gradually  invades  the 
soft  palate  and  pharyngeal  muscles,  causing  difficulty  in 
deglutition;  the  orbicularis  oris  preventing  closure  of  the  lips; 
the  laryngeal  muscles,  interfering  with  articulation.  With  the 
increasing  loss  of  power  in  the  tongue  and  lips  there  is  also  a 
gradual  atrophy  of  these  muscles ;  the  atrophy  usually  antedates 
the  paralysis.  When  the  disease  is  fully  developed,  the  con- 
dition of  the  patient  is  most  pitiable;  articulation  is  impaired 
or  impossible,  and  deglutition  interfered  with,  the  lips  remain- 
ing apart  allowing  the  saliva  to  dribble  from  the  mouth  and 
liquids  to  return  through  the  nose  with  attempts  at  swallowing. 
As  the  malady  progresses,  the  pneumogastric  nucleus  becomes 
involved,  resulting  in  loss  of  voice,  difficulty  of  respiration,  and 
cardiac  irregularity.  The  general  health  gradually  suffers 
from  insufficient  nutrition  and  imperfect  respiration,  although 
the  mind  is  clear  until  the  end.  The  "reactions  of  degenera- 
tion" are  present. 

Besides  the  chronic  bulbar  paralysis,  there  are  two  acute  forms 
with  the  same  symptoms  as  the  chronic  cases,  only  they  develop 
suddenly,  one,  the  result  of  hemorrhage  into  the  medulla,  which 


PROGRESSIVE   MUSCULAR  ATROPHY.  64 1 

at  the  onset  has  vertigo,  vomiting,  loss  of  power  in  the  limbs, 
and  slight  sensory  disturbances,  all  of  which  disappear,  leaving 
the  glosso-labio-laryngeal  paralysis;  the  second  form  comes 
suddenly,  with  fever,  vomiting,  and  loss  of  power  in  the  limbs, 
soon  disappearing,  leaving  the  characteristic  bulbar  symptoms; 
this  variety  is  inflammatory  and  closely  allied  to  acute  polio- 
myelitis. 

Diagnosis. — The  recognition  of  this  disease  is  not  difficult. 
The  paralysis  of  deglutition  is  particularly  characteristic. 

Prognosis. — The  acute  forms  terminate  fatally  within  a  few 
days.  The  chronic  form  lasts  from  one  to  five  years  and  tdti- 
mately  terminates  in  death  from  exhaustion,  respiratory  failure, 
or  cardiac  failure. 

Treatment. — The  treatment  is  entirely  symptomatic.  Feed- 
ing should  be  accomplished  by  the  stomach-tube  to  avoid  pul- 
monary aspiration.     Massage  and  galvanism  should  be  employed. 

PROGRESSIVE  MUSCULAR  ATROPHY. 

Synonyms. — Wasting  palsy ;  chronic  spinal  muscular  atrophy ; 
chronic  poliomyelitis;  amyotrophic  lateral  sclerosis. 

Definition. — A  chronic  progressive  motor  paralysis  with  atro- 
phy of  certain  groups  of  muscles.  The  paralysis  is  propor- 
tionate to  the  wasting  or  fibrillary  atrophy. 

Causes. — It  occurs  most  frequently  in  males  between  twenty- 
five  and  fifty  years  of  age  and  in  many  instances  is  hereditary. 
A  predisposition  seems  to  exist  in  those  who  habitually  use  one 
set  of  muscles  (muscular  strain).  Exposure  to  cold  and  damp, 
lead;  syphilis;  injuries  to  the  spinal  column  and  acute  diseases 
as  diphtheria,  measles,  acute  rheumatism,  typhoid  and  typhus 
fevers,  may  influence  its  production. 

Pathologic  Anatomy. — Two  theories  as  to  the  origin  of  the 
pathologic  changes  are  held:  one  that  the  initial  lesion  is  in 
the  cord  (Charcot),  the  other,  in  the  muscular  interstitial  connect- 
ive tissue  (Friedreich). 

The  morbid  alterations  are  of  two  groups — spinal  and  muscular. 

The  spinal  changes  consist  in  the  atrophy  and  degeneration  of 
41 


642  PROGRESSIVE   MUSCULAR  ATROPHY. 

the  anterior  columns,  wasting  and  disappearance  of  the  multi- 
polar ganglion-cells  of  the  anterior  horns  with  hyperplasia  of 
the  neuroglia;  rarely,  the  hyperplasia  extends  to  the  lateral 
columns  (amyotrophic  lateral  sclerosis);  also  atrophy,  and 
degeneration  of  the  anterior  nerve-roots. 

The  muscular  changes  consist  of  a  progressive  wasting  of  the 
muscular  tissue,  with  increase  of  the  interstitial  connective 
tissue.  "  The  final  result  is  that  the  muscle  is  converted  into  a 
mere  fibrous  band  with  numerous  fat  cells,  the  development  of 
this  latter  material  taking  place  outside  of  the  muscular  elements 
and  in  the  newly  formed  connective  tissue ' '  ( Bartholow) . 

Symptoms. — The  invasion  is  gradual,  the  disease  having  been 
in  progress  some  weeks  or  months  before  the  patient  is  aware  of 
its  existence. 

In  the  immense  majority  of  cases,  the  disease  is  permanently 
limited  to  one  or  a  few  groups  of  muscles  in  the  upper,  or  more 
rarely  in  the  lower,  extremities.  The  only  muscles  not  yet 
known  to  be  attacked  are  those  of  mastication  and  those  that 
move  the  eyeball  (Roberts). 

Fibrillary  contraction  is  an  early  symptom,  continuing  more 
or  less  marked  so  long  as  any  muscular  fibers  remain.  It  con- 
sists of  wave -like  movements  of  the  muscles,  excited  auto- 
matically, by  draughts  of  air  or  percussion.  Coincident  with 
the  wasting  there  occur  loss  of  power,  disorders  of  sensation, 
and  coolness  and  pallor  of  the  surface. 

The  natural  roundness  and  contour  of  the  body  and  limbs  are 
changed,  the  bones  standing  out  with  unusual  distinctness,  giv- 
ing the  individual  the  appearance  of  a  skeleton  clothed  in 
skin. 

Four  types  of  the  disease  are  recognized:  i,  the  hand- type;  2, 
the  juvenile  type;  3,  the  infantile  facial  type;  4,  the  peroneal 
type. 

The  hand-type:  Wasting  begins  in  the  hand,  particularly  in 
the  short  muscles  of  the  thumb  and  the  ball  of  the  little  finger — 
the  thenar  and  hypothenar  eminences.  The  complete  atrophy  of 
the  thumb  muscles  produces  such  a  change  in  the  shape  of  the 
hand  as  to  give  it  the  name  of  the  ape-hand.     Soon,  and  may  be 


PROGRESSIVE    MUSCULAR  ATROPHY.  643 

at  the  same  time,  wasting  of  the  dorsal  interosseous  muscles  is 
observed,  with  consequent  loss  of  power  in  these  muscles,  produc- 
ing the  deformity  known  as  claw-hand.  Shortly  the  deltoid  and 
other  arm  muscles  are  involved  in  the  wasting  and  contraction. 

The  juvenile  type  (Erb) :  A  rare  form,  affecting  the  muscles  of 
the  shoulder  and  upper  arm,  and  less  commonly  the  muscles  of  the 
'ower  extremities.  This  form  follows  the  hand-type  after  a  time, 
but  Erb  described  cases  occurring  primarily  in  these  parts. 
Rarely,  wasting  in  the  suprascapular  muscles,  with  fibrillary 
contractions,  is  seen  alone. 

The  infantile  facial  type  involves  the  muscles  of  expression, 
changing  entirely  the  appearance  of  the  individual  and  giving 
the  eyeballs  undue  prominence  from  atrophy  of  the  surrounding 
muscles,  not  unlike  exophthalmos.  After  a  time,  the  muscles  of 
the  shoulder  and  arm  are  involved,  except  the  supraspinatus, 
infraspinatus,  and  the  flexors  of  the  hand  and  fingers. 

The  peroneal  type:  Wasting  first  appears  in  the  muscles  of  the 
legs,  extending  to  the  feet,  producing  single  or  double  club-foot. 
After  a  time  the  muscles  of  the  hands  and  arms  are  involved, 
with  the  consequent  deformities.  Vasomotor  changes  are 
observed  in  this  type. 

Rarely  all  the  types  are  more  or  less  blended  in  the  same  indi- 
vidual. Usually,  the  electro-contractility  is  preserved  so  long 
as  muscular  fibers  remain. 

Diagnosis. — When  wasting  palsy  is  fully  developed,  its  diag- 
nosis is  a  simple  matter.  In  its  early  stages  a  doubt  may 
exist,  but  attention  to  the  history,  symptoms,  and  progress  will 
determine  the  question. 

Syringomyelia  often  begins  with  a  muscular  atrophy  as  a 
marked  symptom,  and  may  be  confounded  with  wasting  palsy, 
the  chief  points  of  distinction  between  which  are:  the  loss  of 
power  of  perceiving  heat,  or  often  to  distinguish  between  heat 
and  cold,  and  the  appearance  of  trophic  changes,  such  as  a  dusky 
or  purplish  hue  of  the  hands,  with  a  uniform  thickness 
resembling  myxedema,  the  development  of  blebs  and  ulcers, 
changes  in  the  nails,  and  sometimes  arthropathies  in  the 
former. 


644  PSEUDO-HYPEB.TROPHIC    MUSCULAR   PARALYSIS. 

Prognosis. — Very  unfavorable,  although  the  danger  to  life  is 
often  very  remote.  The  disease  may  be  arrested  and  remain 
stationary  for  years. 

Treatment. — Internal  medication  seems  to  have  little  or  no 
eflfect  on  the  malady.  In  syphilitic  cases,  mercury  and  potassium 
iodid  should  be  administered  and  if  mineral  poisoning  is  sus- 
pected potassium  iodid  alone  should  be  given.  A  generous  diet 
together  with  the  administration  of  drugs  such  as  arsenic,  strych- 
nin sulphate,  and  cod-liver  oil  is  indicated  in  all  cases.  If  the 
disease  is  the  result  of  overexertion  of  any  group  or  groups  of 
muscles,  these  groups  should  be  placed  at  absolute  rest.  .  Gal- 
vanism applied  locally  to  the  affected  muscles  is  of  great  bene- 
fit. Faradism  is  also  of  value.  Massage,  friction,  and  hot 
sponging  are  useful  adjuvants  to  the  treatment. 

PSEUDO -HYPERTROPHIC  MUSCULAR 
PARALYSIS. 

Synonyms. — Pseudo-muscular  hypertrophy;  lipoma tous  mus- 
cular atrophy;  lipomatosis  luxurians  muscularis. 

Definition. — A  diseased  condition  of  the  muscles  in  which  the 
muscle-fibers  undergo  atrophy  and  are  replaced  by  adipose  and 
connective  tissue,  causing  weakness  and  enlargement  of  the 
muscles. 

Causes. — The  condition  is  first  noticed  in  childhood  and  is 
markedly  influenced  by  heredity.  Certain  families  seem  espe- 
cially predisposed.  Boys  seem  more  liable  to  be  affected  than 
girls. 

Pathology. — Except  in  very  rare  instances  the  structural 
changes  are  confined  to  the  affected  muscles.  Microscopic  ex- 
amination reveals  atrophy  of  the  individual  muscle-fibers  with 
the  disposition  of  adipose  and  connective  tissue  between  them. 

Symptoms. — Weakness  of  the  muscles  with  awkwardness  and 
clumsiness  in  performance  of  ordinary  movements  such  as 
walking,  is  the  earliest  symptom.  This  progresses  and  paralysis 
of  the  extremities  with  muscular  enlargement  is  soon  manifest. 
On  rising  from  a  recumbent  posture  the  patient  gets  up  on  all- 


ACUTE  ASCENDING   PARALYSIS.  645 

fours,  raising  the  trunk  by  moving  the  hands  upon  the  floor, 
eventually  becoming  erect  by  pushing  himself  up  by  his  hands 
on  the  knees.  The  gait  is  waddling.  Electric  excitability  is 
diminished  but  the  reactions  of  degeneration  are  never  obtained. 
Reflexes  are  lessened  and  sometimes  absent.  Disturbances  of 
sensation  and  mental  disorders  are  absent.  As  the  disease  pro- 
gresses, the  patient  ultimately  becomes  bed-ridden  although 
apparently  well  preserved  for  a  long  period.  The  course  is 
indefinite  and  the  outlook  is  unfavorable.  Death  usually  results 
from  some  intercurrent  affection.      Treatment  is  of  no  avail. 

ACUTE  ASCENDING  PARALYSIS. 

Synonym, — Landry's  paralysis. 

Definition. — An  acute  disease  characterized  by  palsy  beginning 
in  the  feet  and  ascending  to  other  muscles  of  the  body,  finally 
involving  the  medulla.  Pain  and  trophic  disturbances  are  ab- 
sent. The  reflexes  are  diminished  or  absent,  but  the  muscles  do 
not  waste,  and  the  sphincters  are  not  involved.  The  affection 
is  rare  and  occurs  most  often  in  3^oung  male  adults.  The 
etiology  and  pathology  are  obscure.  The  onset  is  sudden  and 
the  course  acute,  terminating  usually  in  death  within  a  week, 
occasionally  being  prolonged  three  or  four  weeks.  The  treat- 
ment is  unsatisfactory. 

SPINAL  SCLEROSIS. 

Definition. — A  myelitis;  an  increase  in  the  connective  tissue 
of  the  spinal  cord,  with  atrophy  of  the  nerve-structure  proper. 

Varieties. — I.  Lateral  sclerosis.  II.  Posterior  sclerosis,  or 
locomotor  ataxia.  III.  Ataxic  paraplegia.  IV.  Cerebrospinal 
sclerosis. 

Causes. — Generally  there  is  an  hereditary  neuropathic  predis- 
position. The  affection  occurs  most  often  in  males  between  the 
ages  of  thirty-five  and  fifty-five.  Among  the  principal  etiologic 
factors  may  be  mentioned  syphilis,  alcoholism,  mineral  poisons, 
shock  or  injuries  to  the  cord,  overexertion,  and    exposure  to 


646  PRIMARY  LATERAL  SCLEROSIS. 

cold  and  wet.  It  is  said  that  railroad  engineraen  and  firemen, 
as  well  as  conductors  and  other  trainmen,  suffer  from  this  and 
other  spinal  diseases  by  reason  of  the  continual  concussion  of 
railway  travel.  The  freedom  from  the  disease  in  the  negro  has 
been  noted  by  Mitchell. 

Pathologic  Anatomy. — The  changes  in  the  cord  are  gradual  in 
their  development  and  follow  a  longitudinal  instead  of  a  trans- 
verse direction.  The  form,  consistency,  and  color  of  the  cord 
are  altered,  it  being  atrophied,  indurated,  and  of  a  grayish 
color.  The  changes  are  hyperplasia  of  the  connective  tissue, 
with  granular  degeneration,  atrophy  and  disappearance  of  the 
nerve-elements  proper.  The  nerve-roots  undergo  the  same 
fibroid  change.  The  joints  undergo  remarkable  atrophic 
degeneration — the  arthropathies  or  Charcot  joints,  consisting 
of  an  osseous  hyperplasia,  the  joint  enlarging  to  an  enormous 
extent. 

PRIMARY  LATERAL  SCLEROSIS. 

Synonyms. — Anterolateral  sclerosis;  spasmodic  tabes  dor- 
salis  (Charcot) ;  spastic  spinal  paralysis  (Erb) ;  amyotrophic 
lateral  sclerosis. 

Definition. — A  degeneration  of  the  lateral  columns  of  the  cord, 
characterized  by  paraplegia,  contractures  of  the  muscles,  with 
exaggerated  reflexes. 

Pathology. — The  exact  morbid  condition  is  still  a  subject  of 
discussion.  The  site  of  the  lesion  is  the  lateral  white  columns, 
in  some  cases  extending  to  the  anterior  horn,  and  involving  the 
whole  length  of  the  cord.  The  changes  consist  in  an  interstitial 
hyperplasia  of  the  connective  tissue,  and  an  atrophy  of  the 
nerve-elements. 

Symptoms. — The  onset  of  the  disease  is  very  gradual,  with 
increasing  feeling  of  heaviness  and  weakness  in  the  limbs, 
progressing  to  a  complete  paraplegia.  There  are  also  jerking 
and  twitching  with  cramps  and  stiffness  of  the  muscles  of  the 
paretic  limbs.  The  spasms  of  the  legs  gradually  increase  in 
extent  as  the  power  lessens,  until  at  last  the  legs,  whenever 


PRIMARY  LATERAL  SCLEROSIS.  647 

extended,  pass  into  a  condition  of  strong  extensor  spasm,  rigidly 
fixing  them  to  the  pelvis,  so  that  the  patient  lies  rigid;  if  one 
leg  is  lifted  from  the  couch  by  the  observer,  the  other  leg  is 
moved  also.  The  spasm  may  be  such  that  the  knee  cannot  be 
passively  flexed  by  any  force  that  can  be  applied  to  it,  until 
the  spasm  has  lessened.  When  flexed,  the  limb  is  compara- 
tively supple;  but  if  it  is  then  extended,  the  spasm  instantly 
returns,  making  the  limb  rigid,  and  often  completing  the  exten- 
sion, just  as  the  blade  of  a  knife  opens  out  under  the  influence 
of  its  spring,  "clasp-knife  rigidity."  Occasionally  there  occur 
brief  flexor  spasms,  drawing  the  legs  up.  The  knee-jerk  is 
greatly  exaggerated,  and  there  can  also  be  developed  rectus 
clonus  and  ankle  clonus.  Electro-contractility  is  impaired 
early  and  gradually  declines  until  abolished. 

Seguin  called  attention  to  "  a  desire  to  micturate  that  is  far 
less  controllable  than  it  should  be  in  a  healthy  person." 

The  spastic  gait  is  characteristic,  termed  by  Hammond  "the 
waddle";  the  legs  drag  behind  and  are  moved  forward  as 
a  rigid  whole,  the  toes  catching  against  the  ground,  the  patient 
showing  a  tendency  to  fall  forward. 

Sensation  is  unaffected.  As  the  morbid  process  extends  up- 
ward, the  superior  extremities  suffer  in  the  same  manner  as  the 
lower. 

Diagnosis. — The  gradual  development  of  weakness  in  the  legs, 
excess  of  myotatic  irritability,  and  spasms  with  developing 
spastic  gait  render  the  diagnosis  clear.  If  the  symptoms  develop 
suddenly  or  acutely,  the  morbid  condition  is  not  of  the  degener- 
ative variety. 

Prognosis. — Complete  recovery  is  rare.  If  the  condition  is 
early  recognized,  its  progress  may  be  held  in  check  for  a  long 
time. 

Treatment. — Rest  is  of  great  importance  and  every  means 
should  be  taken  to  improve  the  general  health.  Massage  and 
warm  baths  are  of  value.  When  the  affection  can  be  attributed 
to  syphilis  or  mineral  poisoning,  increasing  doses  of  potassium 
iodid  or  gold  and  sodium  chlorid  should  be  administered.  Silver 
nitrate  or  silver  oxid  often  retards  the  hyperplasia  of  connective 


648  LOCOMOTOR  ATAXIA. 

tissue.  Benefit  may  sometimes  follow  the  use  of  a  weak  gal- 
vanic current  but  as  a  rule  electricity  is  disappointing  in  central 
diseases. 

LOCOMOTOR  ATAXIA. 

Synonyms. — Tabes  dorsalis;  posterior  spinal  sclerosis. 

Definition. — A  chronic  degeneration  of  the  posterior  colums  of 
the  spinal  cord  and  the  posterior  nerve-roots,  characterized  by 
loss  of  coordination,  neuralgic  pains  in  the  limbs,  loss  of  sensa- 
tion and  reflexes,  and  visceral  and  trophic  changes. 

Causes. — The  disease  usually  attacks  males  between  the  ages 
of  twenty  and  fifty,  one-half  of  the  cases  occurring  between 
thirty  and  forty  years  of  life.  The  most  potent  etiologic  factor 
appears  to  be  syphilis,  although  alcoholism,  exposure,  trau- 
matism, etc.,  may  be  considered  as  contributory  factors. 

Pathology. — It  may  be  considered  as  a  general  disease  of  the 
nervous  system  affecting  both  central  and  peripheral  portions 
though  mainly  limited  to  sensory  or  afferent  structures  (Peter- 
son). It  is  also  described  as  a  progressive  destructive  process 
which  has  a  selective  influence  on  certain  tracts  in  the  posterior 
columns  with  their  roots  and  ganglia  and  to  a  less  extent  on  the 
peripheral  nerves,  particularly  the  optic.  The  nerve-fibers  of 
the  cord  are  first  involved.  Their  destruction  is  not  a  simple 
wasting,  but  is  accompanied  with  evidence  of  irritation,  such  as 
swelling  of  axis-cylinders  and,  secondarily,  proliferation  of 
connective  tissue  and  slight  congestion  (Dana). 

The  degenerated  portions  of  the  cord  appear  grayish  or  slightly 
pinkish  and  translucent,  and  somewhat  depressed.  The  pia 
is  slightly  thickened  and  may  be  turbid.  Microscopically,  the 
disease  begins  on  either  side  in  the  posterior  nerve-root  and 
extends  into  the  posteroexternal  columns  of  Burdach  while  at 
higher  levels  the  posterointernal  columns  of  Goll  are  also  in- 
volved. The  posterior  vesicular  columns  of  Clarke,  the  marginal 
zone  of  Lissauer,  and  the  medullary  bridge  of  Weigert  may  at 
times  be  affected.  The  morbid  process  usually  begins  and 
is  most  marked  in  the  dorso-lumbar  segment  of  the  cord. 


LOCOMOTOR  ATAXIA.  649 

.  Symptoms. — Locomotor  ataxia  may  be  divided  into  three 
periods:  i,  disturbances  of  sensation;  2,  loss  of  coordinating 
power;  3,  paralysis. 

The  onset  of  the  disease  is  gradual,  characterized  by  sharp, 
darting,  electric-like  pains  in  the  lower  limbs,  with  disorders  of 
the  gastrointestinal  and  genitourinary  tracts.  Associated  with 
the  pains  is  a  loss  of  sensation  in  the  feet,  the  patient  being  un- 
able to  distinguish  between  hard  and  soft  substances  in  walking, 
and,  if  the  upper  portion  of  the  spinal  cord  be  affected,  is  unable 
to  coordinate  the  muscles  of  the  fingers  sufficiently  to  button  his 
clothing.  The  sensation  of  formication  over  the  surface ,  especially 
over  the  lower  limbs,  and  about  the  waist,  the  knee,  and  the 
ankle,  is  present;  there  is  nearly  always  a  feeling  of  constriction 
about  the  trunk — the  girdle. 

Loss  of  coordination,  or  ataxia,  is  manifested  by  the  subject 
being  unable  to  walk  upon  a  straight  line  with  his  eyes  closed, 
and  with  difficulty  if  his  eyes  are  opened.  There  is  inability  to 
preserve  the  erect  position  with  the  feet  close  together,  the  body 
swaying  widely  and  the  patient  falling  on  attempting  to  stand 
with  closed  eyes — Romberg's  symptom;  and  as  the  malady 
progresses  the  patient  throws  his  feet  and  legs  in  the  most 
grotesque  manner  when  walking.  Although  the  patient  is 
unable  to  coordinate  the  muscles,  their  power  is  not  lost,  for, 
on  being  supported,  he  can  kick  or  strike  with  his  usual  force. 
The  sight  is  early  impaired,  due  to  atrophy  of  the  optic  nerve, 
causing  either  double  vision  or  inability  to  distinguish  between 
different  colors.  Very  early  there  is  loss  of  pupil-reflex  to  light, 
the  reaction  to  accommodation  being  preserved — Argyll- 
Robertson  symptom.  Ocular  palsies  may  also  occur.  As  the 
disease  progresses,  sensation  becomes  more  and  more  blunted 
and  pain  is  slowly  recognized,  frequently  several  minutes  elaps- 
ing before  the  pricking  of  a  pin  is  appreciated.  A  characteris- 
tic sign  of  the  disease  is  the  abolition  of  the  patellar  tendon - 
reflex — Westphal's  symptom — as  well  as  other  reflexes  in  the 
lower  limbs.  Loss  of  the  sensation  of  temperature  also  occurs. 
The  electro-contractility  is  decreased  in  the  affected  limb. 
General  emaciation  is  marked. 


650  LOCOMOTOR  ATAXIA. 

Vasomotor  and  trophic  symptoms,  more  or  less  pronounced, 
occur  in  all  cases.  "Perforating  ulcers"  of  the  feet,  circum- 
scribed loss  of  hair,  changes  in  the  nails,  and  local  sweatings  are 
the  more  common.  Muscular  atrophy,  either  localized  or 
general,  is  not  infrequent. 

Frankel,  under  the  term  "hypotonia,"  describes  a  condition 
found  in  tabetic  persons  in  which  the  patient,  lying  on  a  fiat 
surface,  can  completely  straighten  his  legs  when  at  right  angles 
to  the  body,  which  cannot  be  done  by  a  normal  man,  whose 
knees  will  be  bent  when  the  thighs  are  at  right  angles  with  the 
body. 

Either  early  or  late  in  the  disease,  occur  disturbances  in 
micturition  and  loss  of  sexual  power  and  often  desire.  There 
also  occur,  in  a  fair  number  of  cases,  painless  swelling  and  dis- 
integration of  various  joints,  particularly  the  knee  and  elbow 
— the  tabetic  arthropathies,  or  Charcot  joints. 

At  any  period  of  the  disease,  peculiar  crises  or  neuralgic 
attacks  occur;  if  griping  pains  in  stomach  with  vomiting,  gastric 
crises;  if  renal  pain  or  colic  with  disturbed  urinary  flow,  neph- 
ritic crises;  if  pain  in  bladder,  vesical  crises;  if  pain  in  rectum 
with  hemorrhoids,  rectal  crises;  if  severe  paroxysm  of  coughing, 
bronchial  crises;  if  constriction  of  the  throat  with  dyspnea, 
laryngeal  crises;  if  cardiac  pain  and  tachycardia,  cardiac  crises. 

Paralysis  finally  ends  the  suffering  of  the  patient.  There  is 
generally  an  entire  absence  of  cerebral  phenomena,  although 
rarely  delusions  or  dementia  develop  toward  the  end  of  the 
malady. 

Diagnosis. — There  are  four  pathognomonic  symptoms  of  loco- 
motor ataxia,  the  presence  of  which  makes  the  diagnosis  positive; 
they  are  Westphal's  symptom — absence  of  patellar  reflex; 
Romberg's  symptom — swaying  of  body  and  inability  to  main- 
tain erect  position  with  closed  eyes;  the  Argyll- Robertson  symp- 
tom— loss  of  pupil  reflex  to  light,  but  reaction  to  accommodation 
retained;  Frankel's  symptom — hypotonia. 

Chronic  myelitis  is  characterized  by  paralysis,  and  the  course 
of  the  affection  is  otherwise  so  different,  that  an  error  should  be 
impossible. 


LOCOMOTOR  ATAXIA.  65 1 

Disease  of  the  cerebellum  presents  symptoms  of  disordered  co- 
ordination, but  they  are  the  result  of  vertigo,  and  are  associated 
with  headache,  nausea,  and  vomiting,  with  absence  of  neuralgic 
pains  and  eye  symptoms. 

Paraplegia  is  a  true  paralysis,  while  locomotor  ataxia  is  not. 
Neuralgic  pain  is  not  a  symptom  of  paraplegia. 

Gastralgia  may  simulate  the  gastric  crises  of  locomotor  ataxia, 
but  the  history  and  attendant  phenomena  will  serve  to  make  a 
distinction. 

Multiple  neuritis  shows  loss  of  power  with  pain  and  tenderness 
but  does  not  present  the  four  pathognomonic  symptoms  men- 
tioned above. 

Prognosis. — The  outlook  is  unfavorable.  T?ie  disease  runs  a 
chronic  and  progressive  course  extending  over  several  years 
with  occasional  remissions.  Stationary  periods  may  be  encount- 
ered. Ill  the  early  stages  the  progress  may  be  retarded  by 
treatment.  The  affection  ultimately  ends  in  death  by  some 
intercurrent  disease. 

Treatment. — Absolute  rest,  preferably  in  bed,  over  an  ex- 
tended period  is  essential  to  the  proper  management  of  each 
case.  Excitement,  mental  exertion,  and  sexual  excesses  should 
be  avoided.  Measures  should  be  taken  to  improve  the  general 
health  independently  of  the  nervous  condition.  For  this 
purpose  nutritious  food,  cod-liver  oil,  hypophosphites,  strych- 
nin, etc.,  are  indicated.  The  association  of  syphilis  with  this 
affection  calls  for  the  administration  of  potassium  iodid  and  the 
bichlorid  of  mercury  in  full  doses.  The  chlorid  of  gold  and 
sodium,  gr.  1/20  (0.003  gm.),  three  times  daily,  often  serves  to 
retard  the  progress  of  the  disease.  The  best  medicinal  results  are 
obtained  from  the  use  of  silver  nitrate,  gr.  1/4  to  1/2  (0.016  to 
0.03  gm.),  or  silver  oxid,  gr.  1/2  (0.03  gm.),  three  times  daily, 
withholding  the  drug  at  intervals  of  a  few  weeks  to  prevent 
discoloration  of  the  skin  (argyria). 

Massage  and  systematic  exercise  are  of  great  value.  The 
system  of  Frankel  in  which  the  patient  is  made  to  re-leam  co- 
ordination and  practise  the  same,  from  the  most  simple  to  the 
most  complex  movements,  is  undoubtedly  productive  of  great 


652  ATAXIC   PARAPLEGIA. 

benefit.  Many  modifications  of  this  system  are  in  vogue  all  of 
which  are  adapted  to  individual  cases  and  differ  little,  if  any,  in 
principle.  The  employment  of  cold  along  the  spine  in  the  form 
of  cold  sponging,  cold  spinal  pack,  or  short  application  of  the 
cold  douche  is  of  value.  The  application  of  the  galvanic  con- 
tinous  current  along  the  spinal  column  with  faradism  to  the 
wasting  muscles  is  strongly  advocated. 

In  the  second  stage,  the  suspension  treatment  of  Charcot  has 
been  followed  by  temporary  improvement.  It  consists  in  the 
suspension  of  the  patient  during  a  period  varying  from  one  to 
four  minutes,  by  means  of  the  Sayre  apparatus  for  applying  the 
plaster  jacket  in  spinal  deformities. 

The  pains  require  rest  in  bed  and  the  administration  of  analge- 
sics. Counterirritation  over  the  nerve-root  supplying  the  pain- 
ful part  often  relieves  the  distress.  Massage  and  the  alternate 
hot  and  cold  douche  are  sometimes  of  benefit.  The  actual 
cautery  applied  to  the  back  once  a  month  is  said  to  relieve 
the  pains.  The  faradic  brush,  static  spark,  and  anodal 
application  of  the  galvanic  current  may  be  of  value.  Resort 
to  opium  or  one  of  its  derivatives,  however,  is  nearly  always 
necessary. 

The  various  other  symptoms  should  be  treated  on  general 
therapeutic  principles  as  they  arise.  When  there  is  increased 
arterial  tension  nitroglycerin  should  be  used,  but  its  use  must 
be  guarded  when  aortic  insufficiency  is  present.  Cannabis 
indica  is  sometimes  of  value. 


ATAXIC  PARAPLEGIA. 

Synonym.— Combined  lateral  and  posterior  sclerosis. 

Definition. — A  chronic  degeneration  of  the  lateral  pyramidal 
tracts  and  of  the  posterior  columns  of  the  spinal  cord,  character- 
ized by  gradually  developing  paraplegia,  with  ataxia  and  spasms 
of  the  limbs. 

Causes. — The  causes  are  not  so  well  determined  as  in  other 
varieties  of  spinal  sclerosis. 


CEREBROSPINAL    SCLEROSIS.  653 

Pathology. — A  sclerosis  of  the  lateral  and  posterior  columns  of 
the  spinal  cord  is  a  constant  structural  change.  It  is  to  be  noted 
that  the  posterior  columns  show  the  morbid  changes  higher  up 
than  in  locomotor  ataxia— the  dorsal  rather  than  the  lumbar 
regions — and  that  the  root-2one  of  the  postero-extemal  column 
is  much  less  involved.  Nor  do  the  lateral  tracts  show  the  same 
degree  of  involvment  as  in  spastic  paraplegia. 

Symptoms. — The  onset  is  slow  and  gradual,  with  loss  of  power 
in  the  lower  extremities.  The  muscles  involved  are  particularly 
the  flexors  of  the  thigh  and.  knee..  One  leg  may  be  weaker  than 
the  other.  There  is  also  ataxia,  the  patient  being  unsteady  when 
standing  with  feet  together  (tabetic  swaying),  and  he  tends  to 
fall  if  the  eyes  are  at  the  same  time  closed.  Spasms  of  the  lower 
extremity  gradually  develop  and  finally  become  as  marked  as  in 
spastic  paraplegia.  The  knee-jerk  reflex  is  increased,  quick  and 
extensive,  and  rectus  and  ankle  clonus  can  be  developed.  The 
sexual  power  is  lost  early.  Incontinence  of  urine  is  frequent. 
Sensation  is  unimpaired,  and  neuralgic  pains  are  absent,  as  are 
also  eye  symptoms. 

Diagnosis. — The  conditions  ataxic  paraplegia  is  most  liable 
to  be  mistaken  for  are  locomotor  ataxia  and  spastic  paraplegia. 
The  presence  of  knee-jerk  and  loss  of  power  in  lower  extremities 
are  of  value  in  discriminating  from  locomotor  ataxia.  Spastic 
paraplegia  is  not  associated  with  ataxia — indeed,  ataxic  para- 
plegia is  spastic  paraplegia  plus  incoordination. 

Prognosis. — Unfavorable.     The   condition   is   progressive. 

Treatment. —  The  same  plan  of  treatment  may  be  tried  as  rec- 
ommended for  lateral  or  posterior  sclerosis. 


CEREBROSPINAL  SCLEROSIS. 

Synonyms. — Multiple  sclerosis  of  the  brain  and  cord; 
cerebral  sclerosis;  spinal  sclerosis;  disseminated  sclerosis 
(Charcot). 

Definition. — A  degenerative  disease  of  the  brain  and  spinal 
cord,  characterized  by  pains  in  the  back,  disorders  of  sensation, 


654  CEREBROSPINAL   SCLEROSIS. 

loss  of  coordination,  tremor  on  motion,  scanning  speech,  and 
some  mental  impairment. 

Pathology. — The  disease  consists  in  the  development  of  patches 
of  grayish,  translucent,  tough  nodules,  varying  in  size  from  a 
microscopic  object  up  to  the  size  of  a  walnut,  varying  in  number 
and  widely  distributed  in  the  white  matter  of  the  hemispheres, 
ventricles,  optic  thalamus,  corpus  striatum,  peduncles,  pons,  and 
cerebellum,  while  in  the  cord  they  are  found  in  both  the  white 
and  gray  matter  and  in  the  columns.  The  deposits  are  also 
found  in  the  nerve-roots  and  nerve-trunks.  The  nodules 
are  composed  of  the  neuroglia,  much  altered,  and  a  newly 
formed  connective  tissue.  The  result  of  the  growth  of  the 
nodules  is  pressure  upon  the  nerve-structure  ending  in  its 
degeneration. 

Symptoms. — The  affection  may  be  considered  as  of  three  vari- 
eties, depending  upon  the  site  of  the  most  marked  changes ;  cere- 
bral, spinal,  or  mixed.  The  latter  variety  is  the  more  common. 
It  is  observed  in  younger  individuals  than  are  the  other  forms 
of  sclerosis. 

The  onset  is  usually  insidious  and  is  attended  by  more  or  less 
severe  pains  in  the  limbs  and  back,  which  the  patient  attributes  to 
rheumatism,  and  a  sensation  of  formication,  itching  and  burning 
in  the  limbs.  A'^ery  rarely,  the  malady  is  ushered  in  with 
apoplectiform  symptoms.  Loss  of  coordination  of  the  hands 
in  writing,  or  of  the  feet  in  walking,  soon  becomes  manifest, 
followed  after  a  time  by  paresis,  more  or  less  general,  with  con- 
tracture of  the  muscles.  Voluntary  movements  of  the  paretic 
limbs  develop  a  tremor  which  subsides  when  the  limbs  are  at 
rest — intentional  tremor.  It  is  increased  by  excitement.  It 
extends  to  the  head  and  neck  causing  shaking  of  the  head  on 
raising  it  from  a  pillow,  or  a  similar  movement.  An  early  and 
frequent  symptom  is  nystagmus.  The  loss  of  coordination, 
with  tremor  and  with  contractures  of  the  muscles  of  the  legs, 
gives  rise  to  the  "waddle"  or  "  hop  gait"  when  walking.  The 
speech  is  slow,  scanning,  or  slurring  in  character.  There  are 
also  present  headache,  vertigo,  and  mental  impairment,  together 
with  an  unnatural  contentment  of  the  feelings  and  with  the  sur- 


CEREBROSPINAL    SCLEROSIS.  655 

roundings.  Disorders  of  vision  from  optic  atrophy  and  dis- 
turbances of  hearing  may  occur.  Sexual  impairment,  vesical 
disorders,  gastric  and  other  crises,  and  bed-sores  may  also  be 
symptoms  of  this  condition.  The  knee-jerk  and  wrist-jerk 
are  exaggerated  and  ankle  clonus  is  present.  The  disease 
is  progressive,  the  symptoms  developing  as  the  various 
nerve-tracts  are  invaded.  Trophic  disturbances  are  seldom 
present. 

The  duration  of  the  disease  ranges  from  one  to  twenty  years, 
the  average  being  five  to  ten  years.  During  this  period  the 
patient  is  very  liable  to  develop  pulmonary  tuberculosis  or 
chronic  nephritis. 

Diagnosis. — The  following  group  of  symptoms,  characteristic 
of  this  disease,  should  prevent  any  error  in  diagnosis;  pains  in 
the  limbs  and  back,  loss  of  coordination  in  the  feet  and  hands, 
muscular  weakness  with  contractures,  intentional  tremor, 
nystagmus,  scanning  speech,  disordered  vision,  increased 
reflexes,  and  vertigo. 

Paralysis  agitans  may  be  mistaken  for  disseminated  sclerosis. 
The  chief  points  in  the  diagnosis  are  the  presence  in  paralysis 
agitans  of  the  fine  tremor  continually  without  shaking  of  the 
head,  with  a  peculiar  flexion  and  rigidity  of  the  hand,  while  in 
cerebrospinal  sclerosis  the  tremor  is  produced  only  on  move- 
ment of  the  muscle,  and  is  associated  with  shaking  of  the 
head.  Paralysis  agitans  is  a  disease  of  middle  life,  sclerosis 
occurs  under  forty  years.  Changes  in  the  voice,  speech,  and 
vision  are  present  in  cerebrospinal  sclerosis,  but  absent  in 
paralysis  agitans. 

Tumor  of  the  pons  or  cms  is  accompanied  by  wild,  jerky  inco- 
ordination closely  resembling  disseminated  sclerosis,  but  tumor 
also  has  headache,  vomiting,  optic  neuritis,  local  spasm,  and 
local  paralysis. 

General  paralysis  of  the  insane  and  disseminated  sclerosis  are 
frequently  confounded,  as  are  locomotor  ataxia  and  primary 
lateral  sclerosis.  A  careful  consideration  of  the  character- 
istic symptoms,  already  mentioned,  will  serve  to  make  a 
distinction. 


656  HEREDITARY  ATAXIA. 

Prognosis. — Unfavorable.  The  disease  slowly  but  steadily 
progresses,  chronic  nephritis  or  tuberculosis  frequently  develop- 
ing and  causing  death. 

Treatment. — There  is  no  drug  having  the  power  to  cure  scler- 
osis. Syphilis  is  the  cause  of  the  majority  of  the  cases,  and 
potassium  iodid,  in  large  doses,  may  sometimes  hold  the  disease 
in  check  for  a  time. 

Attention  to  the  general  health  and  remedies  to  promote  con- 
structive metamorphosis  will  prolong  life,  and  add  to  the  com- 
fort of  the  individual.  Massage,  hydrotherapy,  electricity,  and 
systematic  exercises  may  be  of  benefit  and  should  be  given  a 
fair  trial. 

HEREDITARY  ATAXIA. 

Synonyms. — Friedreich's  disease;  hereditary  ataxic  paraplegia. 

Definition. — A  sclerosing  disease  of  the  lateral  and  posterior 
columns  of  the  spinal  cord  which  shows  a  predilection  for 
certain  families  and  occurs  at  an  earlier  age  than  locomotor 
ataxia. 

Causes. — The  etiology  is  obscure.  The  affection  occurs  in 
a  number  of  the  members  of  the  same  family  and  manifests 
itself  between  the  ages  of  two  and  twenty-four. 

Symptoms. — The  essential  features  of  this  disease  are  ataxia 
and  paraplegia.  Pains  are  seldom  present.  Irregular  jerky 
movements  of  the  head,  impaired  speech,  disordered  vision,  loss 
of  muscular  power,  and  diminished  reflexes  are  common.  Sen- 
sory phenomena  are  seldom  marked  and  trophic  disturbances 
are  unusual.  Deformities  of  the  feet  and  lateral  spinal  curva- 
tures are  not  infrequent. 

Treatment. — The  treatment  is  unsatisfactory.  The  disease 
tends  to  progress,  although  the  course  may  be  extremely  slow 
and  extend  over  several  years.  The  measures  recommended  in 
locomotor  ataxia  are  applicable  to  this  affection. 


HEREDITARY  ATAXIA. 


657 


Differential  Diagnosis  of  Chronic  Diseases  of  the  Spinal  Cord. 

From  Wheeler  and  Jack's  Handbook  of  Medicine. 

Table  I. 


Locomotor  ataxia.  I     Ataxic  paraplegia.     )    Friedreich's  ataxia. 


Age 

Middle-aged  men . , 

Early      middle      life ; 
males. 

Childhood  or  early 
youth. 

Causes 

The  toxic  effects  of 
syphilis,     rarely 
other  toxins. 

Exposure      to      cold, 
traumatisms,  etc. 

Occurs  in  many  of  the 
same  generation. 
Neurotic  predisposi- 
tion. 

Ocular  symptoms. 

Various     muscular 
paralyses     or 
palsies. 

• 

r  Argyll  -  Robert- 

\      son  pupil. 

[  Nystagmus 

Present 

Absent 

Lost 

Absent 

Absent 

Absent. 

Present. 

Tendon        reflexes 
(knee-jerk) . 

Increased . 

Lost. 

Disorders  of  sensa- 

Lightning         pains 
prominent ;    girdle 
sensation ;    numb- 
ness of  feet. 

Absent 

Absent  usually;  occa- 
sional paresthesias. 

Incoordination  .  .  . 

Characteristic  gait;' 
lower  limbs  chiefly 
affected,        upper 
limbs  later. 

Ataxia              marked ; 
spasm    and    rigidity 
also      present,      and 
tend  to  increase. 

Marked,  but  irregular 
and  jerky;  may 
affect  upper  limbs. 

Speech 

Unaffected 

Seldom  affected 

Often  affected. 

Table  II. 


Progressive 
muscular  atrophy. 


Amyotrophic 
paralysis. 


I        Primary  spastic 
paraplegia     (lateral 
sclerosis). 


Limbs         most    Upper   —   atrophy 
affected.  begins    in    thenar 

and  hypothenar 
eminences.  Uni- 
lateral at  first. 


Deformity 


Tendon 
(knee) . 


The        "claw-like" 
hand. 


reflexes    Unaffected. 


Electrical  changes.  I 


42 


Reaction  of  degen- 
eration sometimes 
present. 


Upper  —  atrophy 
may  begin  in  mus- 
cles of  forearm  or 
deltoid.   Unilateral. 


Flexion  of  elbow,  pro- 
nation of  hand,  flex- 
ion of  wrists,  and 
fingers  into  palms. 


Unaffected . 


Partial  R. 
minished 
bility. 


D.   or   di- 
e  X  c  i  t  a- 


Lower — no  atrophy, 
but  rigidity  and 
spasm  are  present. 
Bilateral. 


Adduction  of  legs. 
They  may  cross  each 
other. 


Exaggerated  on  both 
sides. 

Normal  as  a  rule. 


658  SYRINGOMYELIA. 

SYRINGOMYELIA. 

Synonym. — Syringomyelitis. 

Definition. — A  chronic  disease  of  the  spinal  cord,  character- 
ized by  the  formation  of  cavities  in  the  substance  of  the  cord, 
associated  with  loss  of  the  perception  of  pain  and  temperature 
over  certain  regions,  and  complicated  with  muscular  weakness 
and  atrophy,  and  at  times  trophic  changes. 

Causes. — The  true  cause  is  unknown.  The  affection  is  rare 
and  occurs  most  often  in  males  between  the  ages  of  ten  and  forty 
years.  Hemorrhage  and  traumat-ism  of  the  cord  are  believed  to 
influence  its  production  considerably. 

Pathologic  Anatomy. — There  is  present  a  tubular  cavity  or 
cavities  in  the  substance  of  the  spinal  cord,  the  development  of 
which  is  the  subject  of  considerable  discussion.  It  is  thought 
that  they  may  originate  in  either  a  faulty  closure  of  one  of 
the  divisions  of  the  primary  central  canal  of  the  cord,  for  in  the 
course  of  development  the  primary  central  canal  of  the  cord  be- 
comes divided  into  two  parts — an  anterior  and  a  posterior.  The 
anterior  division  forms  the  permanent  central  canal.  The  walls 
of  the  posterior  division  gradually  come  together  and  form  the 
posterior  fissure.  The  imperfect  closure  of  either  of  these  divi- 
sions of  the  primary  central  canal  may  give  rise  to  syringomyelia. 
Or,  the  abnormal  cavity  or  cavities  may  depend  on  the  disinte- 
gration of  a  gliomatous  formation  which  originates  generally  in 
embryonal  tissue  about  the  central  canal.  The  cavity  varies 
in  extent  and  location  in  different  cases,  and  it  is  possible  to 
find  marked  changes  on  autopsy  which  gave  rise  to  no  symp- 
toms during  the  lifetime  of  the  individual.  The  cervical  cord 
is  the  usual  seat  of  the  disease. 

Symptoms. — The  condition  develops  slowly  and  insidiously, 
and  is  nearly  always  bilateral.  There  occur  loss  or  diminution 
of  the  perception  of  temperature  (heat  and  cold)  and  pain,  the 
tactile  sense  being  retained;  and  slowly  developing  muscular 
atrophy,  due  to  involvement  of  the  anterior  horns  of  the  cord. 
The  atrophy  usually  affects  the  arm  and  shoulder  of  one  or 
both  sides,  and  it  may  begin  in  the  hand.     Associated  with  the 


CAISSON   DISEASE.  659 

muscular  atrophy  are  muscular  weakness  and  more  or  less 
fibrillary  contractions.  When  the  weakness  involves  the  spinal 
muscles,  scoliosis  follows.  Arthropathies  occur  in  many  cases, 
particularly  involving  the  shoulder-joint.  Trophic  changes 
also  involve  the  skin,  often  advancing  to  ulceration  and  even 
gangrene,  and  rarely  to  painless  felons,  such  as  occur  in  Mor- 
van's  disease.  The  general  health  of  patients  suffers  but  little 
in  syringomyelia. 

The  disease  is  seen  in  many  irregular  types,  the  loss  of  tem- 
perature sense  in  one  part  and  the  loss  of  sensation  of  pain  in 
another,  and  other  irregular  distribution  of  the  characteristic 
phenomena.  The  symptoms  of  other  forms  of  spinal  disease, 
especially  sclerosis,  may  be  present  in  addition. 

Diagnosis. — Progressive  muscular  atrophy  is  apt  to  be  con- 
founded with  syringomyelia  unless  the  changes  in  the  tempera- 
ture and  pain  senses  are  remembered.  Morvan's  disease  is  by 
many  neurologists  classed  as  a  variety  of  syringomyelia. 

Prognosis. — The  affection  is  incurable,  but  the  duration  is 
rather  long,  extending  over  several  years,  often  with  periods  of 
quiescence. 

Treatment. — This  is  unsatisfactory  and  consists  in  measures 
for  the  relief  of  symptoms. 


CAISSON  DISEASE. 

Synonyms. — Diver's  paralysis;  the  "bends." 

Definition. — An  obscure  condition  occurring  in  divers  and 
others  working  under  increased  atmospheric  pressure,  character- 
ized by  paraplegia,  hemiplegia,  anesthesia,  or  apoplectic  attacks 
on  return  to  the  normal  atmosphere.  Increased  atmospheric 
pressure  is  the  sole  cause.  The  patient  has  severe  pain  in  the 
muscles  (and  sometimes  the  joints)  of  the  back  and  legs.  Head- 
ache, tinnitus,  vertigo,  deafness,  and  prostration  may  ox:cur. 
The  manner  in  which  the  symptoms  are  brought  about  is  not 
well  understood.  They  usually  subside  in  from  several  days  to 
a  few  weeks.      Occasionally  death  results. 


66o  SIMPLE   NEURITIS. 

Treatment. — The  affection  may  be  prevented  to  some  extent 
by  avoiding  sudden  changes  in  the  atmospheric  pressure  and 
long-continued  work  under  high  pressure.  Slow  decompression, 
and  a  careful  selection  of  the  workers  will  do  much  to  prevent 
this  disease.  No  worker  should  be  accepted  who  is  suffering 
from  obesity,  arteriosclerosis,  cardiac  weakness,  nephritis,  are 
affections,  anemia  or  chlorosis,  or  neurasthenia.  The  symptoms 
should  receive  the  same  treatment  recommended  under  acute 
myelitis. 


DISEASES  OF  THE  NERVES. 

SIMPLE  NEURITIS. 

Definition. — An  inflammation  of  the  nerve- trunks,  charac- 
terized by  pain,  impaired  sensation,  motor  paralysis,  and  atrophy. 

Causes. — Among  the  principal  causes  may  be  included  wounds, 
injuries,  and  compression  of  the  nerves,  extension  of  adjacent 
inflammation,  exposure  to  cold  and  wet,  rheumatism,  gout, 
infectious  fevers,  syphilis,  and  lead-poisoning.  - 

Pathologic  Anatomy. — Hyperemia  is  the  earliest  change,  and 
is  soon  followed  by  exudation  into  the  nerve-sheath  and  con- 
nective tissue  which  becomes  softened  shortly  and  ultimately 
breaks  down  into  a  diffluent  mass.  The  affected  nerve  is 
consequently  red  and  swollen.  The  microscope  shows  that 
migration  of  white  corpuscles  takes  place  into  the  neurilemma 
and  that  the  fibers  have  undergone  more  or  less  granular  change. 
Recovery  may  take  place  before  the  nerve-elements  are  entirely 
destroyed  by  absorption  of  the  exudate.  Inflammation  of  a 
nerve  may  extend  upward  {neuritis  ascendens)  or  downward 
{neuritis  descendens).  In  long-standing  cases,  the  diseased 
nerves  are  found  to  be  made  up  largely  of  connective  tissue, 
replacing  the  degenerated  structure. 

Symptoms. — The  onset  may  be  accompanied  with  febrile 
reaction.  The  most  decided  symptom  is  pain  with  tenderness 
along  the  course  of  the  nerve-trunk  and  its  peripheral  distribu- 


SIMPLE   NEURITIS.  66  r 

tion,  of  a  burning,  tingling,  tearing,  intense  character,  increased 
by  pressure  or  motion.  If  the  affected  nerve  be  a  mixed  one — 
sensory  and  motor — spasmodic  contractions  and  muscular 
cramps  occur,  followed  by  impaired  motion,  terminating  in 
paresis  of  the  muscles  innervated  by  the  affected  trunk.  The 
sense  of  touch  and  of  pain  are  markedly  impaired,  while  the 
temperature   and   muscular   sense   are   but   slightly   disturbed. 

If  the  inflammation  proceed  to  destruction  of  the  nerve- 
trunk,  wasting  and  degeneration  of  the  muscular  tissue  ensue. 
Various  trophic  changes  also  occur,  such  as  cutaneous  eruptions 
and  clubbing  of  the  nails.  The  electro-contractility  is  impaired 
or  lost. 

Diagnosis. — Myalgia  or  muscular  pain  is  not  associated 
with  paralysis,  nor  does  the  pain  follow  the  course  of  a  nerve- 
trunk. 

Neuralgia  has  the  pain,  but,  as  a  rule,  not  the  tenderness  of 

neuritis. 

Prognosis. — Generally    favorable,     with    proper    treatment. 

Treatment. — The  affected  part  should  be  placed  at  rest. 
Repeated  blistering  along  the  course  of  the  nerve,  preferably 
with  the  Paquelin  cautery,  together  with  the  administration  of 
full  doses  of  potassium  iodid,  is  usually  successful  in  relieving  the 
condition.  Sedative  lotions  will  also  serve  to  lessen  the  pain. 
Sodium  salicylate,  phenacetin,  and  antifebrin  may  be  of  value 
at  times,  but  in  severe  cases  morphin,  hypodermically,  is  neces- 
sary. In  syphilitic  cases,  the  iodids  are  indicated,  and  in  those 
due  to  exposure  to  cold  and  wet  and  rheumatism,  the  salicylates 
and  alkalies  are  of  great  value.  In  all  cases  quinin  sulphate, 
gr.  ii  to  V  (0.13  to  0.3  gm.),  every  four  hours,  shotild  be  employed 
from  the  onset.  As  the  acute  symptoms  subside,  galvanism  or 
a  feeble,  slowly  interrupted  faradic  current  should  be  used  to 
restore  the  functional  activity  of  the  affected  nerve  and  the 
muscles  to  which  it  is  distributed.  Potassium  iodid  and 
strychnin  during  this  period  are  also  of  value.  If  there  are  any 
manifestations  of  anemia,  iron  together  with  malt  and  the 
hypophosphites  should  be  administered. 


662  MULTIPLE    NEURITIS. 

MULTIPLE  NEURITIS. 

Synonyms. — Polyneuritis;  peripheral  neuritis;  disseminated 
neuritis;  degenerative  neuritis;  pseudo-tabes;  alcoholic  par- 
alysis. 

Definition. — A  parenchymatous  inflammation  of  a  number 
of  symmetric  peripheral  nerves,  simultaneously  or  in  rapid 
succession;  characterized  by  pain,  numbness,  loss  of  power, 
or  ataxia,  with  muscular  atrophy.  Mental  symptoms  are  often 
associated. 

Causes. — Multiple  neuritis  arises  from  a  number  of  causes  all 
of  which  are  toxic  in  character  and  possess  a  predilection  for  the 
nerve-fibers.  The  principal  poisons  introduced  from  without 
that  may  induce  the  affection  are  alcohol,  lead,  arsenic,  silver, 
mercury,  phosphorus,  anilin,  benzine,  carbon  bisulphid,  and 
ergot.  The  internal  causes  include  the  toxins  of  syphilis, 
leprosy,  malaria,  acute  infectious  jaundice,  diabetes,  diphtheria, 
typhoid  fever,  septicemia,  small-pox,  rheumatism,  gout,  chorea, 
and  cachectic  states. 

The  affection  occurs  usually  in  adults  between  the  ages  of 
twenty  and  fifty.  It  may  occur  in  children  as  a  complication  of 
acute  anterior  poliomyelitis  and  diphtheria.  The  female  sex 
is  most  often  attacked.  Emotional  disturbances,  anemia, 
and  exposure  to  cold  may  act  as  exciting  causes.  Alcoholic 
multiple  neuritis  is  the  most  common  form  of  the  disease. 

Pathologic  Anatomy. — The  affection  is  generally  bilateral 
and  symmetric.  An  important  characteristic  is  its  peripheral 
distribution,  the  inflammation  being  most  intense  at  the  extrem- 
ities of  the  nerves,  lessening  progressively  toward  the  center,  usu- 
ally terminating  before  the  nerve-roots  are  reached.  The  inflam- 
matory process  affects  the  nerve-fibers  primarily  and  the  sheath 
and  connective  tissue  secondarily — a  parenchymatous  inflam- 
mation. The  affected  muscles  are  paler  and  smaller  than  nor- 
mal, the  fibers  being  reduced  in  size  and  undergoing  granular 
changes. 

Symptoms. — The  onset  may  be  sudden,  even  overwhelming, 
causing  rapid  death,  but  is  usually  subacute  or  chronic  from  the 


MULTIPLE   NEURITIS.  663 

beginning.  According  to  the  symptoms,  the  affection  may  be 
divided  into  three  forms,  motor,  sensory,  or  ataxic. 

The  motor  form  manifests  itself  in  motor  weakness,  chiefly  in- 
volving the  flexors  of  the  ankles,  the  extensors  of  the  toes,  and 
the  extensors  of  the  wrists  and  fingers,  situated  in  the  forearm. 
Inflammation  of  the  anterior  tibial  or  peroneal  nerve  in  the  leg, 
and  the  radial  branch  of  the  musculospiral  in  the  arm  is  com- 
mon, resulting  in  the  double  "foot-drop"  and  "wrist-drop"  so 
characteristic  of  this  disease.  Any  of  the  nerves  of  the  body 
may  be  affected,  the  motor  symptoms  varying  with  the  individ- 
ual nerves.  Muscular  atrophy  begins  early  and  progresses  with 
the  disease.     The  steppage  gait  is  often  observed. 

The  sensory  for 'in  shows  itself  in  pains,  tenderness,  tingling, 
and  numbness  with  loss  of  cutaneous  sensibility.  At  times  the 
hyperesthesia  of  the  extremities,  especially  the  soles  of  the  feet 
and  the  muscles,  is  so  marked  that  the  slightest  touch  cannot 
be  borne. 

The  ataxic  form  is  characterized  by  incoordination  with  or 
without  sensory  disturbances,  but  with  loss  of  muscular  sense. 

These  forms  may  exist  combined  to  a  greater  or  less  extent. 
Atrophy  of  the  muscles,  feeble  or  absent  knee-jerks,  and  absent 
or  diminished  electro-contractility  are  common  to  all  forms. 
Trophic  changes  may  occur  in  the  nails,  hair,  and  skin.  A 
characteristic  glossy  condition  of  the  skin  with  some  edema 
often  results  from  involvement  of  the  vasomotor  nerves. 
Rarely  the  vagus,  optic  nerve,  and  laryngeal  nerve  are  attacked. 

An  acute  variety  of  the  disease  may  occur,  in  which  the  affec- 
tion is  ushered  in  with  fever,  101°  to  103°  F.,  rapid  feeble  pulse, 
headache,  nausea,  vomiting,  and  delirium  or  convulsions 
shortly  followed  by  various  combinations  of  the  motor,  sensory, 
and  ataxic  phenomena  already  described. 

The  chronic  variety  is  unattended  by  febrile  symptoms  and 
begins  insidiously  with  pains  and  other  sensory  disturbances, 
followed  by  weakness  and  wasting  of  the  muscles,  and  the  other 
characteristic  manifestations  of  this  disease. 

Alcoholic  m,ultiple  neuritis  is  attended  by  several  character- 
istics  which   serve   to   distinguish   it.     Foot-drop   is   a   typical 


664  MULTIPLE   NEURITIS. 

symptom  and  there  may  be  delirium,  mania,  and  delusions 
associated  with  tremors.  This  variety  usually  affects  all  the 
limbs  beginning  in  the  flexors  of  the  feet,  being  thus  separated 
from  the  malarial  form  in  which  the  legs  are  first  involved;  the 
diphtheria  type,  in  which  the  pharyngeal  and  ocular  muscles 
are  first  attacked;  the  rheumatic  in  which  the  muscles  of  the 
face  are  first  affected;  and  the  lead  variety,  which  begins  in  the 
arms. 

Diagnosis. — The  distinctive  features  of  this  affection  are  its 
symmetric  distribution,  pain  and  tenderness  over  the  nerve- 
trunks,  peripheral  nerves  and  muscles,  the  .various  sensory 
phenomena,  and  the  loss  of  power  with  wasting  of  the  muscles, 
beginning  in  the  extremities.  The  history  of  some  toxic  condi- 
tion will  also  aid  in  making  the  diagnosis.  A  careful  considera- 
tion of  these  characteristics  will  serve  to  differentiate  the  condi- 
tion from  Landry's  disease,  neuralgia,  locomotor  ataxia,  rheu- 
matism, hysteria,  poliomyelitis,  and  other  affections  with  which 
it  might  be  confused. 

Prognosis. — The  outlook  is,  as  a  rule,  favorable,  if  early  and 
proper  treatment  be  instituted.  Involvement  of  the  respiratory 
muscles  in  acute  cases  may  be  the  cause  of  a  fatal  termination. 
In  long-standing  cases,  the  probability  of  restoration  of  the 
affected  muscles  to  normal  is  not  very  great. 

Treatment. — The  primary  cause  should  be  ascertained,  and,  if 
possible,  promptly,  removed.  Absolute  rest  in  bed  is  of  great 
importance.  Pressure  upon  the  affected  parts  should  be 
carefully  avoided.  The  parts  should  be  wrapped  in  cotton- 
wool or  flannel,  and  moist  or  dry  heat  and  sedative  lotions  or 
ointments  should  be  applied.  Temporary  relief  may  be  afforded 
by  change  in  position  of  the  limbs,  but  unusual  positions  should 
not  be  long  maintained  on  account  of  the  possibility  of  contrac- 
tion of  the  muscles  and  subsequent  deformity.  Antifebrin 
and  similar  preparations  may  be  of  beneflt  but  in  severe  cases 
morphin,  hypodermically,  is  necessary. 

There  is  no  speciflc  medication  for  polyneuritis.  In  alcoholic 
cases,  strychnin  nitrate  should  be  used;  in  malarial  cases,  quinin 
sulphate;  in  diphtheritic  cases,   tincture  of  the  chlorid  of  iron 


BERI-BERI.  665 

and  strychnin  sulphate;  in  rheumatic  cases,  sodium  salicylate, 
salol,  or  phenacetin;  in  syphilitic  cases,  mercury  and  potassium 
iodid;  and  in  lead  and  other  mineral  poisonings,  the  iodids  should 
be  employed.  In  all  cases,  a  generous  nutritious  diet  with  the 
administration  of  tonics  is  necessary. 

During  convalescence,  moderate  exercise,  massage,  and  mild 
galvanism  should  be  prescribed.  Arsenic  during  this  period  is 
considered  to  be  of  great  value  as  a  constructive  tonic. 

BERI-BERI. 

Synonyms. — Kakkd;  endemic  multiple  neuritis. 

Definition. — An  endemic  and  epidemic  form  of  multiple 
neuritis,  occurring  in  tropical  and  subtropical  countries,  and 
characterized  by  motor  and  sensory  paralysis,  anemia,  and 
general  edema. 

Etiology. — Unknown.  Two  theories  are  held:  i.  That  it 
is  an  infection;  but  the  specific  organism  is  not  yet  determined. 
2.  That  it  is  a  toxmia,  caused  by  food,  either  bad  rice  or 
certain  fish.  Both  theories  may  be  correct.  Contaminated 
drinking  water,  a  nitrogenous  diet,  and  unsanitary  surroundings 
are  important  etiologic  factors. 

Pathologic  Anatomy. — Peripheral  neuritis,  with  degeneration 
of  the  axis-cylinders  and  myelin  sheaths;  the  pneumogastric 
and  phrenic  may  be  attacked  as  well  as  the  peripheral  nerves. 
Degeneration  of  muscle  fibers  in  the  heart  and  voluntary 
muscles  may  also  be  found. 

Symptoms. — Incubation  period  a  month  or  more.  The 
affection  is  manifested  by  evidences  of  multiple  neuritis,  car- 
diac irritability,  anasarca,  and  a  generalized  tired  feeling.  In 
acute  cases,  there  are  fever,  anemia,  anasarca,  emaciation,  and 
dyspnea.  The  neuritic  changes  induce  atrophy  and  paralysis 
of  the  muscles.  In  severe  forms  there  may  ensue  paralysis 
of  heart  or  larynx  or  diaphragm. 

Prognosis. — The  mortality  ranges  from  3  to  60  per  cent., 
according  to  the  type  of  the  disease. 

Treatment. — Consists  largely  in  tonic  and  supportive  meastires. 


666  HERPES    ZOSTER. 

The  salicylates,  in  doses  of  gr.  xv  to  xx  (i.o  to  1.30  gm.),  are 
highly  recommended.  For  the  heart,  digitalis,  or  strychnin 
may  be  required;  as  may  glonoin  if  the  arterial  tension  is 
high,  when  gr.  i/ioo  (0.0006  gm.)  may  be  given  every  half 
hour  until  the  other  remedies  have  had  time  to  take  effect. 
The  diet  and  hygiene  should  receive  attention. 

HERPES    ZOSTER. 

Synonyms. — Zona;  shingles. 

Definition. — An  acute,  inflammatory  disease,  characterized 
by  the  development  of  groups  of  firm  and  distended  vesicles 
situated  upon  inflamed  bases  corresponding  to  a  definite  cuta- 
neous nerve,  and  accompanied  by  more  or  less  severe  neuralgic 
pains. 

Causes. — The  eruption  and  consequent  neuralgic  pains  are 
the  immediate  result  of  an  inflammation  of  the  posterior  ganglia 
of  the  spinal  nerve-roots ;  but  the  cause  producing  this  condi- 
tion is  obscure.  Among  the  many  that  have  been  suggested  are: 
cold,  injuries  to  nerves,  anemia,  malaria,  and  the  medicinal  use 
of  arsenic. 

Symptoms. — The"  affection  begins  with  neuralgic  pains, 
either  of  a  burning  or  lightning-like  character,  with  slight 
febrile  phenomena,  followed  by  the  appearance  of  papulovesi- 
cles along  the  tract  of  pain ;  these  soon  become  vesicles  situated 
on  bright  red,  highly  inflamed  bases.  The  vesicles  are  about 
the  size  of  pin-heads,  or,  perhaps,  a  little  larger;  usually  discrete, 
although  they  frequently  coalesce,  forming  irregular  patches, 
appearing  in  groups  until  the  third  to  the  fifth  or  even  tenth 
day,  when  they  gradually  desiccate,  and  at  the  end  of  the  second 
week  nothing  remains  except  occasionally  a  slight  scar,  which 
may  disappear  or  become  permanent.  When  the  eruption  is  at 
its  height,  it  is  perfect  in  its  anatomic  formation,  each  vesicle 
being  well  shaped  and  seated  on  a  bright  red,  inflamed  patch 
of  skin,  and  distended  with  a  translucent,  yellowish  fluid.  The 
vesicles  show  no  tendency  to  rupture  spontaneously.  In  rare 
instances  they  may  become  purulent,  hemorrhagic,  or  gangrenous. 


NEURALGIA.  667 

The  eruption  is  almost  invariably  confined  to  one  side  (uni- 
lateral) of  the  body,  although  in  rare  instances  it  is  seen  upon 
both  (bilateral)  sides.  It  is  usually  found  upon  well-known 
nerve-tracts.  Recurrence  is  rare.  According  to  the  region 
affected  it  is  termed  zoster  capitis,  zoster  frontalis,  zoster  faciei, 
zoster  ophthalmicus,  zoster  auricularis,  zoster  nuchae,  zoster 
brachialis ,    zoster  pectoralis,  zoster  ahdominalis ,  zoster  femoralis. 

Diagnosis. — The  characteristics  of  herpes  zoster  are  the  pains 
preceding  and  accompanying  the  eruption,  the  unilateral 
distribution,  and  the  grouped,  tense  vesicles  showing  no  tend- 
ency to  rupture,  situated  over  the  course  of  a  cutaneous  nerve. 

Prognosis. — Most  cases  terminate  in  recovery  within  ten  days 
or  two  weeks.  Neuralgia  may  follow  the  disappearance  of  the 
eruption.  Herpes  zoster  ophthalmicus  may  give  rise  to  destruc- 
tive ocular  lesions. 

Treatment. — The  pain  will  require  the  administration  of  anti- 
pyrin,  gr.  xv  (i  gm.),  every  three  or  four  hours;  phenacetin,  gr. 
V  (0.3  gm.),  every  three  hours;  sodium  salicylate,  gr.  x  to  xv 
(0.6  to  I  gm.),  every  three  hours;  or  if  very  severe,  morphin, 
gr.  1/8  (0.008  gm.),  and  atropin,  gr.  i/ioo  (0.00065  gm.), 
hypodermically,  near  the  lesion.  The  following  combination 
is  sometimes  of  value: 

]^.      Zinci  phosphidi. 

Ext.  nucis  vomica.  .  .  .aa  gr.  x  aa  o  .  6  gm. 

M.     Ft.  pil  No.  XXX. 
S. — One  every  two  to  four  hours  (Bulkley). 

Locally,  aristol,  boric  acid,  zinc  oxid,  and  similar  powders 
dusted  over  the  lesons  are  of  value.  Flexible  collodion,  con- 
taining morphin,  painted  over  the  vesicles  serves  to  protect 
them  and  lessen  the  pain. 

NEURALGIA. 

Definition. — A  disease  of  the  nervous  system,  manifesting  it- 
self by  sudden  pain  of  a  sharp  and  darting  character,  mostly 
unilateral,   following  the  course   of  the  sensory  nerves. 


668  NEURALGIA   OF    THE   FIFTH   NERVE. 

Varieties. — The  most  important  are  :  I.  Neuralgia  of  the  fifth 
nerve.  II.  Cervicooccipital  neuralgia.  III.  Cervicohrachial  neu- 
ralgia. IV.  D or sointer costal  neuralgia.  V.  Lumbo abdominal 
neuralgia.      VI.  Sciatica.      VII.  Erythromelalgia  (Mitchell). 

Causes. — The  most  important  etiologic  factors  are  adult 
life,  female  sex,  heredity,  anemia,  malaria,  syphilis;  rheumatism, 
metallic  poisons,  gout,  anxiety,  mental  exertion,  exposure  to 
cold  and  damp,  injuries  to  the  nerve-trunks,  and  reflex  disturb- 
ances   such    as    accompany    eye-strain    and    dental    affections. 

Pathology. — The  changes  in  the  nerves  are  very  vague. 
Neuritis  is  frequently  present.  The  true  nature  of  neuralgia  is 
obscure.  An  impoverished  condition  of  the  blood,  perhaps, 
underlies  the  affection. 

NEURALGIA  OF  THE  FIFTH  NERVE. 

Synonyms. — Tic- douloureux;  trifacial  neuralgia;  prosopalgia. 

Symptoms. — Paroxysmal  pain,  of  a  sharp,  darting,  stabbing 
character,  most  common  at  points  along  the  course  of  the  supra- 
and  infraorbital  branches  of  the  fifth  nerve,  attended  with  in- 
creased lacrimation,  is  characteristic  of  this  affection.  When  of 
any  duration,  changes  are  observed  in  the  nervous  distribution, 
such  as  edema  along  the  course  of  the  nerve,  gray  eyebrows, 
and  convulsive  twitches  of  the  muscles,  termed  "  tic -douloureux,'' 
with  tenderness  at  the  infra,-  and  supraorbital  foramina,  as  well 
as  along  the  course  of  the  nerve  distribution. 

CERVICOOCCIPITAL  NEURALGIA. 

Paroxysmal  pain,  of  a  sharp  and  lancinating,  or  deep,  heavy, 
tensive  character,  along  the  course  of  the  occipital  nerve  upon  ■ 
one  or  both  sides,  extending  from  the  vertex,  and  on  the  neck 
as  far  down  as  the  clavicle,  and  upward  and  forward  to  the 
cheek.  It  may  be  associated  with  hyperesthesia  of  the  skin,  and 
with  cramps  in  the  cervical  muscles,  and  with  attacks  of  herpes. 
A  sensation  of  cracking  at  the  nape  of  the  neck  is  an  annoying 
symptom  in  many  cases. 


CERVICOBRACHIAL   NEURALGIA.  669 

CERVICOBRACHIAL  NEURALGIA. 

Paroxysmal  pain  of  a  severe,  boring,  burning,  or  tensive  char- 
acter, with  sensations  of  numbness  and  weakness  of  the  arm, 
hand,  shoulder,  scapula,  and  mamma,  with  tenderness  along  the 
cervical  plexus.  Edema  of  the  arm  and  other  parts  along  the 
distribution  of  the  cervical  plexus  occurs  if  the  neuralgia  be  of 
long  duration;  as  the  result  of  nutritive  changes,  the  limb  at 
times  becoming  pale,  the  skin  glossy,  dry,  and  harsh. 

DORSOINTERCOSTAL  NEURALGIA. 

Paroxysmal  pain,  of  a  sharp,  and  lancinating  character,  along 
the  fifth  and  sixth  intercostal  spaces,  often  associated  with  the 
development  of  herpes  zoster,  or  '^shingles."  Tenderness  is 
present  at  the  points  where  the  nerves  emerge  from  the  inter- 
vertebral foramina  at  the  sides  of  the  chest  and  at  points  in  front. 

LUMBOABDOMINAL  NEURALGIA. 

Paroxysmal  pain,  of  a  sharp  and  lancinating,  at  times  heavy 
and  dull,  character,  following  the  course  of  the  iliohypogastric 
nerve,  ilioinguinal  and  external  spermatic  nerve,  supplying  the 
integument  of  the  hip,  the  inner  side  of  the  thigh,  the  scrotum 
and  labium. 

SCIATICA. 

Paroxysmal  pain  following  the  course  of  the  sciatic  nerve 
usually  as  the  result  of  a  neuritis. 

Symptoms. — Sciatica  usually  follows  an  attack  of  lumbago, 
the  pain  becoming  fixed  in  the  sciatic  nerve ;  at  times  it  is  a  true 
neuritis. 

The  pain  is  sharp,  tearing,  shooting,  or  lancinating  in  charac- 
ter, increased  upon  motion,  shooting  along  the  course  of  the 
nerve  into  the  hip,  inner  side  of  the  thigh,  calf  of  the  leg,  ankle, 
and  heel,  at  one  or  all  of  these  points,  in  paroxysms  lasting  from 
a  few  hours  to  twenty-four  hours  or  longer.     Tactile  sensation  in 


670  ERYTHROMELALGIA. 

the  foot  and  motility  in  the  limbs  are  impaired,  and  if  of  long 
duration,  wasting  of  the  limb  occurs. 

ERYTHROMELALGIA. 

Synonym. — "  Red  neuralgia." 

Symptoms. — In  this  form  of  neuralgia,  the  feet  principally  are 
affected  by  intense  redness  and  burning  pain.  For  a  considera- 
ble period  before  the  condition  is  typically  developed  there  are 
aching  pains  in  the  feet,  particularly  when  used.  The  feet,  in 
Dr.  Mitchell's  words,  "get  redder  and  redder,  the  viens  stand 
out  in  a  few  minutes  as  if  a  ligature  had  been  tied  about  the 
limb,  and  the  arteries  throb  violently  for  a  time,  until  at  length 
the  extremities  become  of  a  dark  purplish  tint."  As  a  rule,  the 
redness  only  occurs  when  the  feet  hang  down,  and  when  at  rest 
they  may  be  pale  and  perspire  freely.  Blisters  and  ulcers 
follow  slight  contusions  of  the  feet.  • 

Diagnosis. — Erythromelalgia  has  been  confounded  with  Ray- 
naud's disease.  The  presence  of  pain,  bright  redness,  throbbing 
and  increased  temperature  of  the  part  are  all  the  opposite  of 
Raynaud's  disease. 

Prognosis  of  All  Forms  of  Neuralgia. — The  attack  can  usually 
be  relieved,  and  in  those  cases  in  which  the  underlying  cause 
can  be  ascertained  and  removed,  the  outlook  is  favorable  for 
permanent  cure.  If  the  neuralgia  is  the  result  of  the  pressure  of 
an  exostosis,  aneurysm,  or  other  tumor,  the  prognosis  is  un- 
favorable. The  variety  known  as  erythromelalgia  is  very 
persistent.  Fifth  nerve  neuralgia  is  likewise  very  obstinate 
to  treatment. 

Treatment  of  Neuralgia  in  General. — During  the  intervals 
between  the  attacks,  the  general  health  should  be  improved  and 
all  possible  sources  of  reflex  disturbance  should  be  carefully  re- 
moved. The  diet  should  be  highly  nutritious  and  medication 
suitable  for  the  individual  case  should  be  employed.  In 
anemic  patients  iron  and  arsenic  should  be  used;  in  rheumatic 
persons,  the  alkalies  and  salicylates  should  be  given;  in  syphilitic 
cases  or  those  due  to  mineral  poisons,  potassium  iodid  should  be 


PROGNOSIS   AND    TREATMENT    OF    NEURALGIA.  67 1 

administered;  and  in  the  presence  of  malaria,  quinin  sulphate 
or  hydrochlorid  should  be  employed.  Undue  physical  or 
mental  excitement,  exposure  to  cold  and  wet,  and  excesses  of 
various  kinds  should  be  avoided.  The  following  pill  is  of  great 
value  in  all  cases: 


r^.      Quininas  sulphat gr-  ij  .13     gm- 

Morphinae  sulphat gr.  1/20  .003  gn^- 

Strychninse  sulphat gr.  1/30  .002  gm. 

Acidi   arsenosi gr.  1/20  .003  gm. 

Extracti  aconiti gr.  1/2  .032  gm. 

M.     Ft.  pil.  No.  j. 

S. — One  every  one,  two,  or  three  hours  (S.  D.  Gross). 


All  forms  of  neuralgia  are  more  or  less  benefited  with: 

I^.      Quininae  sulph gr-  iij  -  2            gm. 

Ferri  reduct gr.  j  .065       gm. 

Acid,   arsenosi gr.  1/20  .003       gm. 

Aconitinae gr.  1/120  .00054  gm. 

M.  S. — In  pill,  every  four  or  five  hours. 


The  condition  of  the  eyes,  ears,  nose,  throat,  and  teeth  should 
always  receive  careful  attention.  The  presence  of  eye-strain, 
cerumen,  adenoids,  dental  caries,  etc.,  may  be  the  origin  of 
re  lex  disturbances  that  ultimately  become  neuralgias.  The 
relation  between  them  is  not  always  apparent  so  that  in  all 
cases  these  structures  should  be  examined  as  a  matter  of 
routine. 

During  an  attack,  the  hypodermic  injection  of  morphin  sul- 
phate and  atropin  sulphate  affords  the  most  prompt  and  ready 
relief.  Acetanilid,  phenacetin,  bromids,  caffein,  salicylic  acid 
preparations,  and  cannabis  indica  may  also  be  used  but  are  less 
efficacious.  Moist  or  dry  heat,  chloroform  liniment,  menthol 
and  chloral-camphor  applications,  acupuncture,  and  counter- 
irritation  may  be  employed  locally. 


672  PROGNOSIS  AND    TREATMENT   OF   NEURALGIA. 

In  trigeminal  neuralgia,  the  following  combination  is  produc- 
tive of  great  benefit: 

I^.     Aconitinae  (Duquesnel) . .   gr.  i/io  .006  gm. 

Glycerini, 

Alcoholis aa    f  5  j  aa  4 .      c.c. 

Aquae  menth.  pip.  q.s.  ad  f  Bij  ad  60.       c.c. 

M.    S. — Teaspoonful,    repeated    from  four   to    eight    times 
daily,  carefully  watched. 

In  intercostal  neuralgia,  the  following  is  recommended 

I^.     Chloral 5j  4 .  gm. 

Pulv.  camphoras 5j  4 .  gra. 

Menthol oj  4 .  gm. 

M.     Mix  and  rub  together. 

S. — Paint  over  painful  parts  with  brush,  as  the  occasion 
requires. 

Facial  neuralgia  is  often  wonderfully  benefited  by  the  admin- 
istration of  fluidextract  of  gelsemium,  n^iii  to  v  (0.2  to  0.3  c.c), 
every  three  or  four  hours  until  its  physiologic  effects  are  pro- 
duced. It  may  be  combined  with  cannabis  indica  or  bella- 
donna. Excellent  results  often  follow  the  use  of  aconite  and 
quinin,  in  pill  form. 

In  sciatica,  antipyrin,  antifebrin,  or  phenacetin,  gr.  xx  (1.3 
gm.),  repeated  two  or  three  times  daily  may  afford  relief. 
Bartholow  recommends  deep  injections  of  chloroform.  Nitro- 
glycerin may  be  of  benefit,  beginning  with  one  drop  of  a  i 
per  cent,  solution,  three  or  four  times  daily,  and  gradually  in- 
creasing the  dose  until  4  or  5  drops  are  taken  several 
times  daily.  Mitchell  advocates  the  application  of  a  flannel 
bandage  to  the  entire  leg,  changed  daily,  and  a  splint  reaching 
from  the  axilla  to  the  heel,  held  closely  to  the  limb.  This 
procedure  insures  absolute  rest  for  the  part.  Tonics  should  also 
be  employed.  A  spray  of  chlorid  of  methyl  along  the  course  of 
the  nerve  for  a  few  moments  often  serves  to  relieve  the  dis- 
tressing pain.  Occasionally,  the  administration  of  full  doses  of 
potassium  iodid  and  the  application  of  a  blister  along  the  course 


FACIAL   PARALYSIS.  673 

of  the  nerve  will  be  of  benefit.  Massage,  acujjuncture,  nerye- 
stiret.ching  and  electricity,  and  similar  procedures  may  be  tried 
in  obstinate  cases. 

In  eryihromelalgia,  medication  has  been  of  no  avail.  Rest 
and  elevation  of  the  limb  affords  relief  in  many  cases.  Mitchell 
recommends  either  nerve-stretching,  or  in  aggravated  cases 
nerve-excision. 

FACIAL  PARALYSIS. 

Synonym. —  Bell's  palsy. 

Definition. — An  acute  paralysis  of  the  seventh  cranial — the 
facial  nerve,  the  great  motor  nerve  of  the  muscles  of  the  face — 
the  nerve  of  expression. 

Causes. — Exposure  to  a  current  of  cold  air  against  the  side  of 
the  face — over  the  pes  anserinus — is  the  most  frequent  cause. 
It  may  also  be  due  to  injury  or  disease  of  the  middle  ear  involv- 
ing the  nerve,  tumor,  blood-clot,  or  abscess  in  the  cortical  area 
or  nucleus  of  the  seventh  nerve,  or  at  the  base  of  the  brain, 
syphilis,  rheumatism,  or  the  infectious  fevers. 

Symptoms. — The  facial  nerve  supplies  the  muscles  of  the  face, 
the  muscles  of  the  external  ear,  also  the  stylohyoid,  posterior 
belly  of  the  digastric,  the  platysma,  one  muscle  of  the  middle 
ear,  the  stapedius,  and  one  palate  muscle,  the  levator  palati; 
by  means  of  the  chorda  tympani  branch  it  controls  the  secretion 
of  the  parotid  and  submaxillary  glands,  and,  possibly,  the  sense 
of  taste.  It  also  furnishes  motor  power  to  the  azygos  uvuls,  the 
tensor  tympani,  and  the  tensor  palati  muscles. 

The  onset  is  usually  sudden,  with  tingling  of  the  lips  and 
tongue  and  upon  looking  into  the  mirror  the  patient  is  surprised 
by  the  perfectly  blank,  motionless  side  of  his  face;  the  comer 
of  the  mouth  is  depressed,  the  eyelids  open,  the  face  drawn 
toward  the  well  side,  and  the  patient  is  unable  to  expectorate, 
whistle,  or  swallow. 

Any  of  the  muscles  innervated  by  the  nerve  may  participate 
in  the  paresis. 

The  electro-contractility  is  feeble  or  lost.  The  reflexes  are 
abolished.     If  there  is  loss  of  taste  in  the  anterior  portion  of  the 

43 


674 


PARALYSIS    OF    THE    LARYNGEAL    MUSCLES. 


tongue,   it  indicates   involvement  of  the   nerve  in   its   passage 

through  the  temporal  bone. 

Diagnosis. — Facial  paralysis,  such  as  accompanies  hemiplegia, 

and  similar  affections  is  attended  by  normal  reflex  excitability 

and  cerebral  symptoms  due  to  involve- 
ment of  other  nerves.  Facial  palsy,  in 
the  presence  of  otorrhea,  imperfect  hear- 
ing, obliquity  of  the  uvula,  and  loss  of 
taste,  is  due  to  a  lesion  of  the  nerve  in 
the  aqueductus  Fallopii.  The  peri- 
pheral form  of  Bell's  palsy  is  complete 
and  the  taste  is  normal  and  the  uvula 
straight. 

Prognosis. — In  cases  of  peripheral  origin 
the  outlook  is  favorable.  In  others,  it 
depends  entirely  upon  the  character  of 
the  underlying  cause  and  the  ease  with 
which  it  may  be  removed. 

Treatment. — In    peripheral  facial  neu- 

^S^tm.^i^i^l^  ^i^i^'  ^h^  bowels  should  be  opened  thor- 
ductor  paralysis     Both  in    oughly   and  the  Salicylates  administered. 

phonation;  3,  unilateral  ab-      ^.       /  .  ,         ■■  -,     , 

ductor  (left)  and   3',  biiat-     Diaphoresis    should   be  obtamed  by  the 

eral  abductor  paralysis  both      1.1,1  1         -1  •  1  ■  •      1 

during  breathing;  4,  left  re-  hot  bath  and  pilocarpm  or  diurcsis  by 
4'^"sTme^11?rSpirat°on^^T''  ^^^^^s  of  potassium  acctatc  and  diluents. 
rSp[;aTiL''?nr'^hinafi°on';     ^listers   should   be   applied   in   front    of 

5,  arytenoid  paralysis  pho-  the  ear.  As  the  acutc  symptoms  sub- 
nation,    5',   Thyro-arj'tenoid         .  .  J       ir- 

paralysis,  phonation;  s"ary-     side,     potassium    iodid     and     Strychnin 

tenoid   and    thyro-arytenoid         ^         ^  ^      ,  .  ^  .  .  ^ 

paralysis.     (Greene's  Medical      Should     be      glVCn      and      galvaniSm      and 

tagnosis.  massage  should  be  applied  to  the  affected 

muscles.  In  cases  due  to  middle-ear  disease  special  treatment 
is  necessary.  In  paralysis  of  central  origin,  the  iodids  may  be 
employed,  but  apart  from  this  medication  is  of  little  avail. 

PARALYSIS  OF  THE  LARYNGEAL  MUSCLES. 

Etiology. — Central  nervous  lesions,  as  bulbar  paralysis;  per- 
ipheral nervous  lesions,  affecting  the  recurrent  laryngeal  nerve 
(such  as  aortic  aneurysm,  tumor  of  mediastinum,  diphtheritic 


Fig.  59. — Vocal  cords 
(Diagrammatic  mirror  pic- 
ture). I,  Normal  position  in 
breathing  and  phonation  re 


CHOREA. 


675 


pa;-alysis);  local  lesions  of  the  vocal  cords  (such  as  ulceration 
dus  to  syphilis,  or  tuberculosis) ;  and  hysteria. 

The  nerves  involved  are  the  superior  laryngeal  and  the 
recurrent  laryngeal  (both  branches  of  the  pneumogastric  nerve). 

The  following  oft-quoted  table  from  Gowers  shows  the 
symptoms,  laryngoscopic  picture,  and  lesions: 


Symptoms. 


Signs. 


Lesion. 


(a)  No  voice ;  no  cough ;  stridor 
only  on  deep  inspiration.. 

(b)  Voice  low-pitched  and 
hoarse;  no  cough;  stridor 
absent  or  slight  on  breath- 
ing. 

(c)  Voice  little  changed ;  cough 
normal;  inspiration  diffi- 
cult and  long,  with  loud 
stridor. 


Both  cords  moderately  abducted; 
and  motionless.  1 

One  cord  moderately  abducted! 
and  motionless,  the  other  mov- 
ing freely  and  even  beyond  the 
middle  line  in  phonation. 

Both  cords  near  together,  and 
during  inspiration  not  separated, 
but  even  drawn  nearer  together. 


(d)  Symptoms  inconclusive;  1  One  cord  near  the  middle  line,  not; 
little  affection  of  the  voice  moving  during  inspiration;  the 
or  cough.  !      other  normal. 


Total    bilateral 
palsy. 

Total     unilateral 
palsy. 


Total  abductor 
palsy. 


Unilateral  abductor 
palsy. 


(e)    No  voice;  perfect  cough;  no ■   Cord  normal  in  position  and  mov-j   Adductor  palsy, 
stridor  or  dyspnea.  ing  normally  in  respiration,  but! 

not    brought    together    on    an 
\     attempt  at  phonation.  | 

Treatment   is   that   of  the   cause;   electricity    and    strychnin 
have  also  been  employed. 


GENERAL  NERVOUS  DISEASES. 
CHOREA. 


Synonyms. — St.    Vitus'    dance;  Sydenham's   chorea. 

Definition. — A  functional  disorder  of  the  nervous  system; 
characterized  by  irregular  spasmodic  fibrillary  movements  of 
groups  of  muscles,  with  weakness,  more  or  less  approaching 
paralysis  of  the  affected  parts.  Excitement  increases  these 
movements,  while  sleep  causes  their  cessation. 

Causes. — It  is  essentially  a  disease  of  childhood,  and  its 
production   may  be   greatly   influenced   by   female   sex,   rheu- 


676  CHOREA. 

matic  diathesis,  habit,  neurotic  temperament,  heredity,  mental 
excitement,  spring  season,  and  reflex  disturbances  such  as 
produced  by  adherent  prepuce,  masturbation,  worms,  dentition, 
eye-strain,  etc.  The  affection  may  be  observed  at  times  during 
pregnancy  and  after  hemiplegia. 

Pathology. — There  are  no  constant  lesions.  Emboli  are 
believed  to  be  the  cause  in  some  cases.  The  affection  is  be- 
lieved by  many  observers  to  be  a  neurosis  and  by  others  an 
infection. 

Symptoms. — The  onset  is  usually  gradual,  the  child  seem- 
ingly grimacing  or  jerking  the  arm  or  hand,  as  if  in  imitation, 
followed  soon  by  decided  irregular  jactitations  of  the  muscles 
of  the  face  (histrionic  spasm),  of  the  eyelids  (blepharospasm), 
eyeballs  (nystagmus),  and  the  shoulder,  arm,  and  hand,  finally 
extending  to  the  lower  extremities,  interfering  greatly  with 
motility;  in  severe  cases  there  is  inability  on  the  part  of  the 
patient  to  feed  himself  or  to  hold  anything  in  the  hands.  The 
speech  is  often  unintelligible,  the  tongue  constantly  moving  in 
an  irregular  manner. 

The  heart's  action  is  tumultuous  and  irregular,  associated 
often  with  a  soft,  blowing,  systolic  murmur,  most  distinct  at 
the  base.  The  muscles  are  usually  quiet  during  sleep,  although 
this  is  not  always  the  case.  The  mind  is  somewhair  blunted, 
the  temper  irritable,  and  the  memory  impaired.  If  the  irregu- 
lar muscular  movements  are  confined  to  one  side  of  the  body, 
it  is  termed  hemichorea. 

Rheumatism  and  endocarditis  may  occur  as  complications 
or  as  sequels. 

Diagnosis. — Chorea  was  confounded  with  epilepsy  until 
the  points  of    distinction    were    pointed    out    by    Sydenham. 

Huntington's  chorea  or  chronic  chorea  is  distinctly  hereditary, 
and,  instead  of  being  fibrillary  contraction  of  muscles,  involves 
whole  groups  of  muscles,  so  that  the  patient  seems  to  be  postur- 
ing and  grimacing,  with  a  dancing  movement,  with  many 
queer  contortions  of  the  face  and  head.  Generally,  all  the 
muscles  of  the  body  are  involved.  It  may  have  associated  the 
fibrillary  muscular  contractions  of  St.  Vitus'  dance. 


CHOREA.  677 

Paralysis  agitans  has  general  muscular  tremor,  beginning  in 
one  limb,  gradually  progressing,  uninfluenced  by  treatment; 
it  is  a  disease  of  the  elderly. 

Post-hemiplegic  chorea  is  the  choreic  movement  of  a  paralyzed 
limb. 

Chorea  insaniens  is  characterized  by  violent  movements 
preventing  ordinary  voluntary  movement  and  attended  by 
fever,  delirium,  and  exhaustion,  sometimes  ending  in  death. 
It  occurs  most  often  in  adults. 

Prognosis. — The  vast  majority  of  cases  recover,  but  relapses 
are  very  frequent. 

Treatment. — The  child  should  be  removed  from  all  excitement, 
mental  and  physical,  and  placed  at  comparative  rest  among  the 
best  hygienic  surroundings.  Many  cases  improve  rapidly  when 
confined  to  bed  in  a,  darkened  room.  The  diet  should  be  light 
and  the  secretions  should  be  rendered  free.  The  cause  should 
be  removed  if  possible.  All  reflex  irritation  such  as  accom- 
panies eye-strain,  intestinal  parasites,  dental  disorders,  adherent 
prepuce,  etc.,  should  receive  appropriate  attention. 

Arsenic  is  the  most  reliable  remedy  yet  introduced  for  the 
treatment  of  this  affection.  It  should  be  pushed  until  its  first 
physiologic  effects  present  themselves,  after  which  the  dose 
should  be  gradually  reduced  until  all  the  symptoms  disappear. 
The  best  preparation  for  use  in  this  connection  is  the  solution 
of  the  arsenite  of  potassium  (Fowler's  solution),  n^v  (0.3  c.c), 
increased  to  ttlx  (o  .  6  c.c),  or  even  n^xv  (i  c.c),  three  times  daily. 
Fluidextract  of  cimicifuga,  n^xx  to  f5i  (1.3  to  4  c.c),  three 
times  daily  is  of  value,  especially  in  cases  following  rheumatism. 
Those  cases  resisting  arsenical  medication  may  rapidly  improve 
under  hyoscyamin  hydrobromid,  gr.  1/200  to  i/ioo  (0.00032  to 
0.00065  gm.),  three  times  daily.  Obstinate  cases  occasionally 
respond  to  antipyrin,  gr.  x  (0.6  gm.),  four  times  daily.  Quinin 
is  also  of  benefit  at  times.  In  anemic  individuals  iron  sho\ild 
be  administered.  If  the  muscular  movements  interfere  with 
sleep,  recourse  should  be  had  to  hyoscin,  bromids,  chloral,  or 
morphin  sulphate. 


678  EPILEPSY. 

EPILEPSY. 

Definition. — A  chronic  disease,  of  which  the  characteristic 
symptom  is  a  sudden  loss  of  consciousness,  attended  with  more 
or  less  general  convulsions. 

Causes. — True  epilepsy  almost  always  arises  first  during  the 
growth  and  development  of  the  brain.  Heredity  exercises  a 
very  strong  predisposing  influence.  The  family  history  in 
many  cases  contains  records  of  insanity,  epilepsy,  hysteria,  and 
similar  conditions  in  the  relatives  of  the  patient.  Worry, 
anxiety,  depression,  fright,  syphilis,  uterine  disease,  brain 
tumor,  and  meningeal  thickening  may  at  times  be  etiologic 
factors.  Reflex  irritation  from  intestinal  parasites,  eye-strain, 
etc.,  may  induce  epileptoid  convulsions  which  if  long-continued 
may  bring  about  true  chronic  epilepsy.  The  affection  usually 
manifests  itself  before  puberty  and  seldom  begins  after  twenty- 
five  years  of  age. 

Pathologic  Anatomy. — There  are  no  constant  anatomic  lesions, 
as  yet,  associated  with  essential  epilepsy. 

In  " Jacksonian,"  "cortical,"  or  "partial  epilepsy,"  however, 
the  "motor  cortex"  is  irritated  by  disease  and  there  occur  tonic 
and  clonic  spasms  of  the  same  character  as  in  general  epilepsy, 
confined  to  a  single  arm,  or  an  arm  and  half  the  face  together, 
or  maybe  the  entire  half  of  the  body.  These  epileptiform  at- 
tacks furnish  precise  data  as  to  the  locality  of  the  lesion ;  spasms 
affecting  the  distribution  of  the  facial  nerve  point  to  the  lower 
third  of  the  central  convolution;  of  the  arm,  the  middle  third 
of  the  central  convolution;  of  the  lower  extremity,  the  upper 
third  of  the  central  convolution. 

Varieties. — I.  Epilepsia  gravior,  le  grand  mal.  II.  Epilepsia 
mitior,  le  petit  mal. 

Symptoms.— Le  grand  mal  is  preceded  by  a  more  or  less  pro- 
nounced and  curious  sensation,  the  so-called  aura  epileptica. 

The  attack  proper  is  sudden,  the  subject  suddenly  falling,  with 
a  peculiar  cry,  loss  of  consciousness,  and  pallor  of  the  face,  the 
body  assuming  a  position  of  tetanic  rigidity,  succeeded  after  a 
few  moments  by  more  or  less  pronounced  clonic  convulsions, 


EPILEPSY.  679 

followed  by  coma,  of  several  hours'  duration.  The  subject 
awakens  with  a  confused  or  sheepish  expression,  with  no  knowl- 
edge of  what  has  occurred,  unless  he  has  injured  himself  during 
the  attack,  either  by  the  fall,  or,  what  is  very  common,  has 
bitten  his  tongue  during  the  convulsions.  When  the  convul- 
sions follow  each  other  in  rapid  succession  without  any  interven- 
ing periods  of  consciousness,  the  condition  is  termed  status 
epilepticus.  The  convulsive  outbreaks  may  be  followed  by 
maniacal  attacks  or  the  condition  known  as  epileptic  autom- 
atism, during  which  various  acts  are  performed  unconsciously  by 
the  patient. 

Le  petit  mal  is  manifested  either  by  attacks  of  vertigo,  the  con- 
sciousness being  preserved,  or  by  a  passing  absent-mindedness, 
either  form  being  associated  with  slight  convulsive  phenomena 
followed  by  slight  coma,  or  mental  confusion  of  short  duration. 

The  mental  functions  are  not,  as  a  rule,  injured  by  attacks  of 
epilepsy,  unless  they  recur  ver}^  frequently.  Indeed,  when  at 
wide  intervals,  the  subject  seems  relieved  by  them,  "  the  sudden, 
excessive,  and  rapid  discharge  of  gray  matter  of  some  part  of 
the  brain  on  the  muscles,"  the  so-called  "electric  storm," 
having  cleared  the  cerebral  atmosphere. 

The  great  majority  of  epileptics  suffer  from  chronic  gastric  ca- 
tarrh, and  have  at  the  same  time  an  inordinate  appetite  (bou- 
limia) ;  indeed,  an  attack  of  gluttony  may  immediately  precede 
a  fit.  The  liability  of  patients  suffering  from  epilepsy  to  de- 
velop tuberculosis  and  nephritis  is  very  great. 

Diagnosis. —  Uremic  convulsions  closely  resemble  epileptic 
attacks,  btit  the  dropsy  or  general  edema  and  albuminous  urine, 
and  increased  temperature  of  the  former  should  guard  against 
error. 

Hysteria  or  feigned  convulsions  may  mislead  the  most  prac- 
ticed expert.  In  convulsions  of  this  character,  however,  con- 
sciousness is  seldom  completely  lost ;  the  patient  is  never  injured 
in  any  way;  the  temperature,  pulse,  and  respiration  remain 
normal;  arching  of  the  back  occurs  (opisthotonos  is  absent  in 
epilepsy);  and  the  duration  is  longer.  In  epilepsy,  there  is 
primary  pallor  of  the  face  which  is  followed  by  a  dusky,  livid. 


68o  EPILEPSY. 

and  swollen  appearance  during  the  convulsion,  this  being  re- 
placed by  ordinary  congestion  during  the  period  of  coma. 
Relaxation  of  the  sphincters  is  common  in  attacks  of  grand  mal. 

Organic  brain  disease  may  be  distinguished  from  epilepsy  by  the 
occurrence  of  its  convulsions  at  a  much  later  period  in  life,  the 
character  of  the  convulsions,  and  the  history  of  injury,  syphilis, 
etc.  Jacksonian  epilepsy  begins  as  a  spasm  of  a  limb  or  some 
portion  of  a  limb,  and  is  confined  there,  or  may  gradually  ex- 
tend until  even  a  general  convulsion  occurs. 

Prognosis. — In  idiopathic  epilepsy  the  prognosis  is  unfavor- 
able ;  the  vast  majority  of  cases  will  not  be  arrested  by  treatment, 
but  the  frequency  and  severity  of  the  attacks  will  be  greatly 
diminished.  Epileptoid  convulsions  of  reflex  origin  such  as 
sometimes  accompany  intestinal  parasites,  eye-strain,  etc., 
usually  recover  promptly  when  the  cause  is  removed. 

Treatment. — The  attack:  To  avert  an  impending  attack  in- 
halations of  amyl  nitrite,  n-Liii  to  v  (0.2  to  0.3  c.c),  or  a  few 
whiffs  of  chloroform,  or  the  hypodermic  injection  of  morphin 
sulphate  may  be  employed.  Hyoscin  and  chloral  may  also  be 
used.  These  remedies  are  also  indicated  after  the  onset  of  the 
convulsion.  Means  should  be  taken  to  prevent  the  patient 
seriously  injuring  the  tongue;  to  this  end  a  portion  of  a  towel, 
or  a  long  piece  of  wood  such  as  a  clothes  pin,  or  the  handle  of  a 
tooth  brush  should  be  inserted  between  the  teeth.  Small 
objects  so  used  are  dangerous.  The  patient  should  also  be  pre- 
vented from  otherwise  injuring  himself  and  on  the  subsidence 
of  the  convulsion  should  be  placed  comfortably  at  rest  in  a  quiet 
room. 

Status  epilepticus  is  always  a  dangerous  condition,  and  efforts 
to  prevent  it  should  be  made  by  active  medication  the  moment  a 
series  or  group  of  fits  occur.  The  following  combinations  some- 
times are  wonderfully  successful  in  aborting  the  status : 

I^.     Chloral gr.  xxx  2  .  gm. 

Tinct.  cannab.  indicae.  .  .    Tr^xv  i.  c.c. 

Infus.  digitalis f  §j  30.  c.c. 

M.  S. — By  high  enema,  repeated  if  indicated  in  two  or  three 
hours. 


EPILEPSY.  68l 

Dr.  Spratling  (Craig  Epileptic  Colony)  recommends: 


I^.     Tinct.  opii  deodorat ttlv 

Potassii  bromidi gr.  xxx                 2 

Chloral gr.  xx                   i 

Liq.  morph.  (U.  S.) n^iss 

Aquae f  5  ss                   15 

M.  S. — By  mouth,  or,  if  unable  to  swallow,  by  enema. 


3     '^•^'• 
gm. 

3     gm. 

09  c.c. 

c.c. 


A  hypodermic  injection  of  morphin  sulphate,  gr.  1/3  (0.02  gm.), 
and  atropin  sulphate,  gr.  1/60  (o.ooi  gm.),  has  sometimes 
broken  up  a  series  of  epileptic  spasms. 

The  interval:  During  the  interval,  the  patient  should  be  care- 
fully examined  to  determine  the  character  of  any  exciting  causes. 
Reflex  disturbances  of  all  kinds  should  be  promptly  removed  by 
treatment.  The  diet  must  be  carefully  regulated,  excluding  or 
allowing  to  be  used  very  moderately,  meats,  tea,  and  coffee. 
Alcohol  and  tobacco  should  be  interdicted.  The  skin,  kidneys, 
and  bowels  should  be  kept  in  normal  condition  by  appropriate 
measures.  Moderate  exercise  is  of  great  value.  When  the 
patient's  general  condition  is  below  normal,  iron,  arsenic,  quinin, 
and  cod-liver  oil  are  indicated.  Strychnin  is  contraindicated 
as  it  increases  the  tendency  to  convulsive  attacks. 

In  addition  to  the  measures  already  mentioned,  the  frequency 
and  severity  of  the  attacks  may  be  greatly  lessened  by  the 
internal  administration  of  potassium  bromid  in  doses  sufficient 
to  abolish  the  faucial  reflex  and  to  produce  symptoms  of  brom- 
ism.  Combinations  of  the  several  bromids  are  equally  effica- 
cious and  less  irritating  than  the  potassium  salt.  Any  tendency 
toward  the  formation  of  acne  pustules  during  the  administra- 
tion of  the  bromids  may  be  conibated  by  the  addition  of  i 
drop  of  Fowler's  solution  to  each  dose.  When  for  any  reason 
the  bromids  are  inapplicable,  silver  nitrate,  belladonna,  or 
cannabis  indica  may  be  used.  In  syphilitic  cases,  potas- 
sium iodid  should  be  given  in  addition.  In  all  cases  the 
treatment  must  be  continued  for  at  least  two  years  after  the 
last   attack. 


682  EPILEPSY. 

Gowers  highly  recommends  the  following  in  cases  complicated 
with  cardiac  dilatation: 

I^.      Potassii  bromidi gr.  xx  i  .3  gm. 

Tinct.  digitalis nix  .  6  c.c. 

M.  S. — Three  times  a  day,  well  diluted. 

The  following  is  the  combination  used  in  the  insane  wards  of 
the  Philadelphia  Hospital: 

I^.      Sodii  bromidi, 

Potassii  bromidi aa    oiv  aa  16.  gm. 

Liq.  potassii  arsenitis.  .  .    f  oiss  6.  c.c. 

Aquae  menth^  pip f  giij  90  .  c.c. 

Inf.  gentian,  comp.q.s. ad  f§viij  ad  240.  c.c. 

M.   S. — Tablespoonful,   diluted,  three  times  daily. 

Brown-Sequard's  mixture  for  epilepsy  is  as  follows: 

I^.      Potassii  iodidi 8  parts. 

Potassii  bromidi 8  parts. 

Ammonii  bromidi 4  parts. 

Potassii  bicarb 5  parts. 

Inf.  calumba 360  parts. 

M.    S. — One  teaspoonful  before   meals,    and   three   dessert- 
spoonfuls on  going  to  bed. 

The  following  is  an  effective  combination  of  the  "  mixed 
bromids": 

I^.      Sodii  bromidi §j  30.  gm. 

Potassii  bromidi 5vss  22  .  gm. 

Ammonii  bromidi 3iij  12  .  gm. 

Potassii  bicarb oij  8.  gm. 

Inf.  calumba f  5x  300.  c.c. 

Aq.  chloroformi.  .q.  s.  ad   Oj  ad  480.  c.c. 
M.  S. — Tablespoonful  equals  gr.  xxx  (2  gm.). 

Surgical  intervention  may  be  of  value  in  some  cases  of  Jack- 
sonian  epilepsy,  but  in  general  it  is  somewhat  disappointing  in 
its  results. 


HYSTERIA.  683 

HYSTERIA. 

Definition. — A  functional  disorder  of  the  nervous  system,  of 
the  nature  of  which  it  is  impossible  to  speak  definitely;  char- 
acterized by  disorders  of  the  will,  reason,  imagination,  and  the 
emotions,  as  well  as  motor  and  sensory  disturbances. 

Hypochondriasis ,  a  peculiar  mental  condition,  characterized 
by  inordinate  attention  on  the  part  of  the  patient  to  some  real  or 
supposed  bodily  ailment  or  sensation.  A  continual  introspec- 
tion, as  seen  in  males,  is  a  condition  much  like  the  hysteria  of 
the  female. 

Causes. — A  morbid  condition  of  civilization,  confined  prin- 
cipally to  women.  Young  girls,  elderly  single  women,  widows, 
and  childless  married  women  are  the  most  frequent  subjects 
of  the  disorder.  The  paroxysms  frequently  develop  during  the 
menstrual  epoch.  The  menopause  is  another  frequent  period 
for  its  manifestations.  A  peculiar  condition  of  the  nervous 
system,  either  inherited  or  acquired,  is  responsible  for  the  phe- 
nomena of  hysteria,  the  peculiar  manifestations  being  excited  by 
disturbances  of  either  the  sexual,  digestive,  circulatory,  or 
nervous  systems. 

Pathology. — The  true  nature  of  the  affection  is  unknown. 
Structural  changes  are  never  found  except  when  the  condition 
complicates  some  organic  disease. 

Symptoms. — These  will  be  considered  under  the  headings  of 
the  hysteric  paroxysm,  and  the  hysteric  state. 

The  hysteric  paroxysm  or  fit  occurs  nearly  always  in  the  pres- 
sence  of  other  individuals  and  develops  gradually  with  sighing, 
meaningless  laughter,  causeless  moaning,  nonsensical  talking, 
and  gesticulations,  or  a  condition  of  fidgets  followed  with  a 
sensation  of  choking,  dyspnea,  and  a  ball  in  the  throat — the 
globus  hystericus.  These  and  similar  symptoms  precede  the 
fit,  during  which  the  unconsciousness  is  only  apparent,  the 
patient  being  av/are  of  what  is  transpiring  about  her.  During 
the  paroxysm  the  patients  may  struggle  violently,  throwing 
themselves  about,  their  thumbs  turned  in  and  their  hands 
clenched.     Again,   spasmodic  movements  occur,  varying  from 


684  HYSTERIA. 

slight  twitching  in  the  limbs  to  powerful  general  convulsive 
movements,  and  to  almost  tetanic  spasms. 

The  paroxysm  ends  by  sighing,  laughing,  crying,  and  yawning, 
and  a  sensation  of  exhaustion.  During  the  attack  it  will  be 
noted  that  the  surface  and  face  are  normal,  showing  absence  of 
respiratory  embarrassment,  the  breathing  varying  from  very 
quiet  to  spluttering  and  gurgling  sounds,  the  pupils  not  dilated, 
the  pulse  normal,  the  temperature  normal,  and  absence  of 
foaming  at  the  mouth  and  wounding  of  the  tongue. 

The  hysteric  state  is  shown  by  disturbances  of  the  mental  and 
sensory-mxotor  functions,  respectively.  It  may  be  a  permanent 
condition  or  occur  at  intervals  with  greater  or  less  severity. 

Mental  Disturbances. — The  patients  are  emotional,  erratic, 
excitable,  impatient,  and  self-important,  showing  marked 
defects  of  will  and  mental  power. 

Sensory  Disturbances. — These  consist  of  either:  (i)  a  condition 
of  exaggerated  sensibility  or  hyperesthesia,  as  shown  by  the 
marked  effects  from  the  slightest  irritation  and  the  cutaneous 
tenderness  along  the  spine  (the  lower  part  of  the  abdomen,  and 
ovarian  region  are  of  ten  hyperesthetic) ;  or  (2)  a  condition  of 
anesthesia,  as  shown  by  the  apparent  absence  or  recognition 
of  pain  after  severe  irritation,  or  a  perverted  sensibility,  as 
shown  by  the  feeling  of  tingling,  numbness,  and  formication. 
The  anesthetic  area  is  ischemic.  Sensibility  to  heat  or  cold  is 
often  absent.  There  is  great  perversion  of  the  special  senses  in 
many  of  the  cases.  Severe  pain  at  the  top  of  the  head,  as  if  a 
nail  were  being  driven  in  it,  is  peculiar  to  hysteria  and  is  termed 
clavus. 

Motor  Disturbances. — These  phenomena  embrace  every  variety 
of  motor  disturbance,  from  exaggerated  excitable  movements 
to  defective  or  complete  loss  of  power.  With  the  paralysis  that 
may  occur,  neither  nutrition  nor  sensation  is  constantly  im- 
paired. Hysteric  paralysis  is  liable  to  frequent  and  sudden 
changes,  the  loss  of  power  often  disappearing  suddenly.  Apho- 
nia, from  paralysis  of  the  laryngeal  muscles,  is  a  frequent  form 
of  paresis.  Some  hysteric  patients  refuse  to  even  make  an 
attempt    at    speech    (mutism).      Hysteric    contractures    often 


HYSTERIA.  685 

are  most  extensive  and  persistent.  Under  some  emotion  or 
unknown  cause  a  group  or  groups  of  muscles  contract  abruptly 
or  by  degrees,  the  spasms  involving  flexors  or  extensors  or  both 
with  changes  in  reflexes,  and  lasting  for  days  or  years.  Con- 
vulsive seizures  are  common. 

A  curious  enlargement  of  the  abdomen  is  observed  sometimes, 
constituting  the  so-called  phantom  tumor.  This  region  presents 
a  symmetric  prominence  in  front,  often  of  large  size,  with  a 
constriction  below  the  margin  of  the  thorax  and  above  the 
pubes.  The  enlargement  is  qtiite  smooth  and  uniform,  soft, 
very  mobile  as  a  whole  from  side  to  side,  resonant,  but  variable 
on  percussion,  and  not  painful.  Vaginal  examination  gives 
negative  results,  and  under  chloroform  the  prominence  immedi- 
ately subsides,  returning  again  as  the  patient  regains  conscious- 
ness. 

Among  the  numerous  other  s3^mptoms  that  may  develop  in  a 
hysteric  patient  are  disturbances  of  digestion,  circulation,  and 
respiration,  and  disorders  of  micturition  and  menstruation. 

Among  other  phenomena  that  belong  to  the  hysteric  state 
are  to  be  mentioned  hystero-epilepsy ,  a  condition  of  hysteria  to 
which  is  superadded  the  convulsion,  epileptic  in  form ;  catalepsy, 
a  condition  in  which  the  will  seems  to  be  cut  off  from  certain 
muscles,  and  in  whatever  position  the  affected  member  is  placed 
it  will  so  remain  for  an  indefinite  time.  There  may  or  may  not 
be  unconsciousness  and  loss  of  sensation;  trance,  the  individual 
lying  as  if  dead,  circulation  and  respiration  having  almost 
ceased;  ecstasy,  a  condition  in  which  the  individual  pretends  to 
see  visions,  and  acts  in  a  most  ridiculous  manner. 

Diagnosis. — The  hysteric  state  is  so  general  in  its  manifesta- 
tions that  it  is  to  be  borne  in  mind  in  diagnosing  all  ailments 
occurring  in  women.  The  diagnosis  is  attended  with  great 
difficulty,  however,  and  requires  the  display  of  all  the  skill  of 
the  clinician  to  prevent  error. 

It  is  important,  and  sometimes  difficult,  to  differentiate  hysteria 
and  neurasthenia;  Wheeler  and  Jack's  table  is  useful : 


686  HYSTERIA. 


Neurasthenia.  -  Hysteria. 


1.  Occurs  most  often  in  men i.  Women  most  frequently. 

2.  Usually  directly  attributable  to;  2.  Often     seen     amongst     the 
overwork.                                               [  indolent  and  the  rich. 

3.  Little  desire  for  sympathy j  3.  Great  desire  for  sympathy. 

4.  Usually  wasting  is  present 4.  Often  plump  or  fat. 

5.  Very  amenable  to  proper  treat-  5.  Anything  but   amenable   to 
ment.  treatment. 


Prognosis. — Death  from  either  a  hysteric  fit  or  the  hysteric 
state  is  the  rarest  of  events,  if  it  ever  occurs.  The  ultimate 
recovery  of  a  hysteric  patient  is  of  frequent  occurrence.  Mar- 
riage has  cured  many  cases,  although  it  can  hardly  be  advised 
by  the  physician. 

Treatment. — For  the  hysteric  attack,  little  need  be  done,  as  a 
rule,  unless  the  paroxysm  is  violent  or  prolonged,  in  which  case 
valerianate  of  ammonium,  Hoffman's  anodyne,  or  aromatic  spirit 
of  ammonia  may  be  administered.  In  severe  cases,  Charcot 
recommends  making  firm  pressure  over  the  ovarian  region. 

The  management  of  a  confirmed  case  of  hysteria  will  tax  the 
skill  of  the  most  astute  physician.  It  is  in  connection  with 
hysteria  that  the  peculiar  phenomena  supposed  to  arise  from 
applying  different  metals  to  the  surface  of  the  body  have  been 
noticed. 

Moral  and  hygienic  measures  are  of  the  first  importance  in 
the  management  of  hysteric  patients.  The  treatment  of 
hysteric  patients  by  isolation  is  strongly  urged  by  many  special- 
ists. Dr.  S.  Weir  Mitchell  has  devised  a  plan  for  bedfast 
hysteric  patients,  of  massage,  faradization,  and  forced  feeding, 
which  has  been  successful  in  a  number  of  cases. 

There  is  no  fixed  therapeutic  treatment  for  hysteria,  the 
various  symptoms  calling  for  interference  as  they  arise.  It  is 
well,  however,  to  avoid  the  use  of  stimulants,  and  opiates, 
chloral,  and  other  sedatives. 


NEURASTHENIA.  687 

NEURASTHENIA. 

Synonyms. — Nervous     prostration;   nervous  exhaustion;   the 

American  disease. 

Definition. — A  debility  of  the  nervous  system,  causing  an  in- 
ability or  lessened  desire  to  perform  or  attend  to  the  various 
duties  or  occupations  of  the  individual.  It  is  a  purely  functional 
condition. 

Bartholow  describes  it  as  consisting  "  essentially  in  an  exag- 
gerated susceptibility  to  bodily  impressions  and  false  reasoning 
thereon." 

Causes. — Heredity,  neurotic  temperament,  sexual  excesses, 
alcohol,  tobacco,  mental  exertion,  emotion,  overwork,  and 
various  chronic  diseases  are  the  principal  causes.  Men  are 
especially  liable  to  the  affection. 

Symptoms. — Nervous  debility  may  affect  any  organ  of  the 
body.  It  is  a  condition  of  nerve-tire  or  exhaustion,  and  hence 
the  nervous  energy  necessary  for  functional  activity  of  any 
particular  organ  may  be  wanting,  a  fair  example  being  seen  in 
cases  of  nervous  dyspepsia. 

One  of  the  earliest  manifestations  of  nervous  exhaustion  is  an 
irritability  or  weakness  of  the  mental  faculties,  as  shown  by 
inability  to  concentrate  the  thoughts,  and  efforts  to  do  so  caus- 
ing headache,  vertigo,  restlessness,  fear,  and  a  feeling  of  weari- 
ness and  depression,  together  with  an  army  of  symptoms  attend- 
ant on  general  nervousness. 

There  may  be  ocular  disturbances,  cardiac  palpitation,  cold- 
ness of  the  hands  and  feet,  and  chilliness  followed  by  flashes  of 
heat,  followed  in  turn  by  slight  sweating.  Patients  are  troubled 
with  insomnia,  or  fatiguing  sleep,  accompanied  with  unpleasant 
dreams. 

In  the  male  there  are  genitourinary  disorders,  with  pains  in 
the  back,  giving  the  dread  of  impotence.  In  females,  painful 
menstruation,  ovarian  irritation,  and  irritable  uterus. 

The  "  neurasthenic  stigmata"  are :  Feeling  of  pressure  on  head; 
disturbance  of  sleep;  pain  in  back;  muscular  weakness;  dys- 
pepsia; sexual  disorders;  and  mental  disturbances. 


688  Raynaud's  disease. 

Diagnosis. — It  is  of  importance  to  determine  between  a"  true 
nervous  exhatistion  and  nervous  debility  the  result  of  organic 
disease.  A  study  of  the  history  of  the  case,  together  with  the 
symptoms,  should  prevent  error. 

Neurasthenic  symptoms  in  puberty  are  strongly  indicative  of 
mental  instability,  and  great  care  must  be  exercised  to  prevent 
actual  insanity  from  developing. 

For  differentiation  from  hysteria,  see  page  686. 

Prognosis. — Usually  some  mental  weakness  remains  after 
recovery  from  an  attack  of  neurasthenia. 

Treatment. — The  physician  should  remember  that  neuras- 
thenia is  not  a  disease  per  se,  but  that  the  victim  is  a  sick  individ- 
ual needing  the  best  environment,  rest,  and  good  food.  Atten- 
tion to  the  secretions,  diet,  and  surroundings,  with  rest  and  di- 
version of  the  mind  are  essential  to  success.  Travel,  short  of 
fatigue,  pleasant  companionship,  and  relief  from  responsibility 
should  be  advised.  Bathing,  massage,  and  galvanism  are  im- 
portant aids  in  the  management.  In  anemic  and  weak  individ- 
uals the  rest-cure  proposed  by  Dr.  S.  Weir  Mitchell  will  be  of 
value. 

Among  the  internal  remedies  that  are  of  value  in  this  condi- 
tion may  be  mentioned  arsenic,  strychnin,  valerianate  of  zinc, 
phosphorus,  fiuidextract  of  coca,  cocoa  wine,  and  the  compound 
syrup  of  hypophosphites.  Quinin  sulphate  in  small  doses,  gr. 
i  to  ii  (0.065  to  o.  13  gm.),  daily,  for  weeks,  seems  to  lessen  the 
excitability  of  the  nervous  system.  The  following  is  an  excel- 
lent tonic  in  this  affection: 

I^.     Fiuidextract.  cocae f  5ij  8.  c.c. 

Acid,  phosphoric,  dil.  .  .  .    f  ovj  24.  c.c. 

Tinct.  nucis  vomicae f  5ij  8  .  c.c. 

Syr.  zingiberis f  5iss  45  .  c.c. 

Aquag  menthse  pip  q.  s.  ad  fSvj  ad  180.  c.c. 

M.  S. — Tablespoonful  after  meals,  in  water. 

RAYNAUD'S  DISEASE. 

A  very  rare  disease,  characterized  essentially  by  symmetric 
gangrene.     The  cause  is  unknown;  but   there  are  three  chief 


TETANY.  689 

theories  brought  forward  to  explain  the  disease.  These  are 
that  it  is  due  to  (i)  endarteritis  obliterans,  (2)  to  peripheral 
neuritis,  (3)  to  vascular  spasm.  The  affection  is  associated 
with  some  disturbance  of  the  vasomotor  system,  as  a  result  of 
which  local  stagnation  of  the  peripheral  circulation  occurs.  In 
consequence  of  this  there  arise  localized  anemia,  congestion,  and 
finally  gangrene,  symmetrically  distributed.  The  condition 
is  observed  most  often  in  neurotic  women  under  thirty  years  of 
age  and  in  children.  Pain  is  a  prominent  symptom.  The 
treatment  is  unsatisfactory;  the  attacks  continue  but  the  prog- 
nosis as  to  life  is  favorable.  Local  warmth,  friction,  and  gal- 
vanism together  with  the  internal  administration  of  tonics  are 
indicated.  Nitroglycerin,  in  doses  of  gr.  i/ioo  (0.00065  g"^-). 
increased  to  gr.  1/50  (0.0013  gm.),  three  .times  a  day,  has  been 
recommended. 

TETANY. 

Synonyms. — Tetanilla ;  intermittent  tetanus. 

Definition. — A  succession  of  tonic,  usually  bilateral,  painful 
muscular  spasms,  particularly  of  the  extremities,  occurring  at 
irregular  intervals,  without  loss  of  consciousness. 

Causes. — The  true  cause  is  unknown.  Some  cases  are  be- 
lieved to  be  infectious ;  others  are  produced  refiexly  as  in  the  case 
of  those  attacks  associated  with  lavage,  removal  of  the  thyroid 
gland,  pregnancy,  etc.  It  is  usually  seen  in  rachitic  children 
and  young  neurotic  adults.  Heredity,  emotion,  hysteria,  and 
the  infectious  fevers  are  also  etiologic  factors.  The  disease  is 
rare  in  America.     The  pathology  is  obscure. 

Symptoms. — Tetany  consists  in  the  occurrence  of  intermittent 
spasmus  in  the  muscles  of  the  arms,  hands,  legs,  or  feet,  or,  rarely, 
the  face  and  larynx  (laryngismus  stridulus),  associated  with  pain 
or  "cramp."  The  hands  are  thrown  into  a  position  such  as 
they  assume  in  writing,  or  such  as  is  taken  by  the  hand  of  a 
midwife;  or  the  hand  may  be  tightly  closed,  or  one  or  more 
fingers  may  be  cramped.  The  elbows  and  shoulders  may  be 
affected  at  times.  In  the  feet  the  toes  are  drawn  down  and  the 
44 


690  OCCUPATION   NEUROSES. 

instep  upward,  as  in  eqiiinus.  The  knees  may  be  cramped  or 
the  legs  extended.  Any  of  the  muscles  ma}^  be  involved. 
Trousseau  pointed  out  that  in  those  suffering  from  tetany, 
pressure  upon  the  affected  extremities  at  certain  points  will 
excite  the  spasms.  The  duration  of  the  spasms  varies  from  a 
few  moments  to  several  hours,  the  intervals  being  from  an  hour 
to  a  day  or  more.  A  certain  periodicity  is  noticed  as  to  the 
hour  of  the  day  or  night.  The  electro-contractility  is  increased, 
as  are  also  the  reflexes.  Erb  first  described  the  peculiar  gal- 
vanic exaltation  found  in  this  disease.  The  consciousness  is 
always  preserved,  although  the  patients  are  very  nervous. 

Diagnosis. — Tetanus  and  tetany  may  be  confounded,  and  yet 
trismus  is  rare  in  the  latter,  and  always  present  in  the  former. 

Prognosis. — Favorable.  Cases  induced  by  lavage  and  removal 
of  the  th37'roid  may  prove  fatal. 

Treatment. — There  is  no  special  treatment.  The  secretions 
and  excretions  should  receive  attention  and  a  normal  body-tone 
should  be  maintained.  Potassium  bromid,  gr.  xx  to  xl  (1.3  to 
2.6  gm.),  well  diluted,  three  times  daily,  is  often  of  value. 
Urethane  gr.  x  (0.6  gm.),  every  three  or  four  hours,  is  als 
highly  recommended.  Gowers  advises  digitalis  for  the  painful 
cramps  in  the  calves  that  occur  in  the  early  morning  hours 
(nocturnal  tetany).  Gray  has  observed  excellent  effects  follow 
the  application  of  cold  to  the  extremities  and  ice  to  the  spine. 
In  all  cases  when  the  symptoms  are  very  severe  it  may  be 
necessary  to  resort  to  sedatives  such  as  morphin  and  hyoscin. 

OCCUPATION  NEUROSES. 

Synonyms. — Professional  neuroses;  artisans'  cramp. 

Varieties. — Writers'  cramp;  piano-players'  cramp;  teleg- 
raphists' cramp;  violin-players'  cramp;  dancers'  cramp. 

Definition. — A  group  of  affections  of  the  nervous  system, 
characterized  by  the  occurrence  of  spasm  (cramp)  and  pain  in 
groups  of  muscles,  in  consequence  of  overuse  or  frequently 
repeated  muscular  acts. 

Causes. — Undetermined.      It   has   been    noticed    that    many 


PARALYSIS  AGITANS.  69 1 

persons   suffering   from   occupation   neuroses   have   a   neurotic 
family  history. 

Symptoms. — The  manifestations  of  any  of  the  several  varie- 
ties of  this  condition  generally  develop  slowly  with  a  sensation 
of  stiffness  in  the  used  member,  the  part  feeling  fatigued  and 
heavy,  eventually  being  incapacitated  for  work  by  the  occur- 
rence of  spasmodic  contractions.  Attempts  to  move  the  part 
produce  pain  and  often  tremor.  Actual  paralysis  may  be  pres- 
ent. There  is  often  the  sensation  of  pricking  and  numbness 
in  the  affected  member.  The  electro-contractility  is  preserved 
until  atrophy  from  non-use  develops.  Associated  with' the  local 
cha.nges  there  are  nervousness,  mental  worry,  and  often 
depression. 

Diagnosis. — The  history  of  the  case  and  its  results  make  the 
diagnosis  easy. 

Prognosis. — The  outlook  is  often  unfavorable.  Treatment 
should  be  long-continued  as  the  prognosis  is  uncertain.  Obsti- 
nate cases  often  recover  with  persistent  treatment.  Recur- 
rences are  not  uncommon. 

Treatment. — The  affected  part  should  be  placed  at  absolute 
rest.  General  rest  with  mental  quietude  is  also  beneficial. 
The  general  neurotic  condition  of  the  patient  should  receive 
attention.  Locally,  massage,  friction,  faradism,  and  passive 
movements  are  very  efficacious.  The  following  combination 
has  been  employed  with  success: 

I^.      Zinci  phosphidi gr-  ij  .13  gm. 

Ext.  nucis  vomicae gr.  x  .6    gm. 

Ferri  albuminat gr.  xxx  2 .       gm, 

M.     Ft.  pil.  No.  xxx. 
S. — One  after  meals. 

PARALYSIS  AGITANS. 

Synonyms. — Shaking  palsy;  Parkinson's  disease. 

Definition. — A  nervous  disease  of  unknown  pathology, 
characterized  by  tremors,  progressive  loss  of  power  in  the 
affected  muscles,  moderate  rigidity,  with  alterations  in  the  gait, 
and  at  times  mental  impairment. 


692  PARALYSIS  AGITANS. 

Cause. — Age  seems  to  be  an  etiologic  factor,  most  cases 
developing  after  fifty  years.     It  is  most  frequent  in  women. 

Pathologic  Anatomy. — No  characteristic  lesion  has  as  yet 
been  determined.  It  being  a  disease  of  past  middle  life,  there 
is  probably  an  interstitial  hyperplasia  of  some  layer  of  the  cortex 
from  alterations  in  the  intima  of  the  vessels. 

Symptoms. — The  onset  is  gradual,  the  tremor  beginning  in  one 
of  the  extremities,  most  often  the  hand  and  forearm.  At  first  it 
can  be  controlled  by  the  will,  for  a  time  at  least,  and  is  sus- 
pended by  voluntary  movement.  The  disease  gradually 
extends  until  an  entire  side  or  the  upper  or  lower  limbs  are  in- 
volved. The  face  and  head  rarely  present  tremors,  but  are  not 
exempt.  Facial  expression  is  lost  and  speech  is  slow  and  some- 
what measured.  A  peculiar  rigidity  of  the  affected  muscles  is 
characteristic  of  the  advanced  stage.  "At  this  stage  of  the 
disease  the  hands  are  apt  to  assume  the  so-called  bread-crumb- 
ling position,  i.e.,  the  thumb  and  the  fingers  approximate  and 
move  restlessly  over  one  another,  as  in  the  act  of  crumbling 
bread.  There  is  often  a  tendency  on  the  patient's  part  to  go 
forward — so-called  propulsion — and  this  is  sometimes  so 
marked  that  if  the  patient  is  once  started  in  a  walk  forward, 
his  gait  becomes  more  and  more  rapid,  and  he  cannot  stop  him- 
self" (Gray).  The  patients  are  usually  restless  and  annoyed 
with  insomnia.  The  general  health  is  fair.  The  mind  is 
generally  retained,  although  melancholia  and  mild  dementia 
have  been  noted  in  a  few  cases. 

Diagnosis. — Disseminated  sclerosis  has  a  tremor,  but  only  on 
voluntary  movements — intention  tremor.  There  is  also  scan- 
ning speech  and  ataxic  gait,  with  mental  enfeeblement,  as  shown 
by  an  unnatural  contentment  with  the  physical  condition  and 
surroundings. 

Chorea  possesses  a  tremor,  but  the  movements  are  general,  and 
particularly  involve  the  muscles  of  the  face.  Again,  chorea  is  a 
disease  of  children  and  young  adults. 

Prognosis. — Complete  recovery  is  very  rare.  Improvement 
often  results  from  early  treatment.  The  disease  does  not  tend 
to  shorten  life,  but  its  course  is  indefinite. 


MENTAL   DISEASES.  693 

Treatment. — Physical  and  mental  rest  are  necessary  in  all 
cases.  Nutritious  diet,  cod-liver  oil,  hypophosphites,  arsenic, 
and  iron  are  necessary  to  restore  and  maintain  the  general 
health.  Friction,  massage,  bathing,  galvanism,  and  specially 
arranged  gymnastics  are  of  great  value  in  this  condition.  Drugs 
such  as  hyoscyamin  sulphate,  gr.  1/30  to  i/io  (0.002  to  0.006 
gm.),  three  times  daily,  and  hyoscin  hydrobromid,  gr.  1/200 
to  i/ioo  (0.00032  to  0.00065  g^^-)'  three  times  daily,  are  often 
of  benefit. 

ACROMEGALY. 

Acromegaly  is  a  nutritional  disease  of  unknown  origin  charac- 
terized by  marked  enlargement  of  the  osseous  and  soft  structures 
particularly  of  the  face,  hands,  and  feet.  It  occurs  usually  in 
males,  developing  in  most  cases  before  the  age  of  thirty  and  is 
associated  with  disease  of  the  pituitary  body.  In  addition  to 
the  structural  enlargements,  there  are  headache,  polyuria, 
spinal  curvature,  disorders  of  the  special  senses,  headache,  and 
various  neurotic  symptoms.  The  condition  is  incurable.  The 
course  is  chronic  and  may  extend  over  several  years,  death 
ensuing  from  some  intercurrent  disease. 

Treatment  is  of  little  avail.  Extracts  of  pituitary  body, 
thyroid  gland,  spleen,  or  bone-marrow  may  be  administered; 
but  the  physician  should  expect  very  little  benefit,  and  should 
promise  none. 

MENTAL  DISEASES. 

General  Considerations. — An  hallucination  is  a  state  of  the 
mind  in  which  the  patient  believes  he  perceives  external  objects 
that  do  not  exist,  or  in  other  words  is  a  condition  of  false  per- 
ception occurring  independent  of  external  impressions. 

An  illusion  is  a  perverted  impression  based  upon  an  actual 
perception. 

A  delusion  is  a  faulty  belief  concerning  a  subject  capable  of 


694       "  MENTAL   DISEASES. 

physical  demonstration,  out  of  which  the  patient  cannot  be  rea- 
soned by  adequate  methods  for  the  time  being  (H.  C.  Wood). 

A  lucid  interval  (in  insanity)  is  a  period  in  which  there  is  a 
temporary  cessation  of  the  insanity,  or  a  complete  restoration 
to  reason. 

Delirium  is  a  condition  of  mental  aberration  characterized  by 
an  apparent  exaltation  of  all  the  processes  of  the  mind  mani- 
fested by  mental  irritation  and  confusion,  transitory  delusions, 
and  fleeting  hallucinations,  and  by  disordered,  senseless  speech, 
and  by  motor  unrest.  It  may  be  a  part  of  mania,  hysteria,  or 
acute  mania,  or  it  may  be  secondary  to  some  toxic  condition 
such  as  accompanies  uremia,  infectious  fevers,  alcoholism,  etc. 

Definitions  of  Insanity. — There  is  no  satisfactory  definition 
of  insanity. 

According  to  Taylor,  the  term  insanity  is  applied  to  "those 
states  of  disordered  mind  in  which  a  person  loses  the  power  of 
regiilating  his  actions  and  conduct  according  to  the  ordinary 
rules  of  society.  In  all  cases  of  real  insanity  the  intellect  is  more 
or  less  affected." 

Insanity  is  defined,  in  Allbutt's  System  of  Medicine,  as  "such 
a  disorder  or  disease  of  the  nervous  system  as  prevents  the  in- 
dividual from  reacting  normally  as  a  member  of  the  society 
to  which  by  birth  and  education  he  belongs." 

For  other  definitions  see  page  699. 

Idiocy  differs  from  other  states  of  insanity  in  the  fact  that  it 
is  marked  by  a  congenital  deficiency  of  the  mental  faculties. 
There  is  not  here  a  perversion  or  a  loss  of  what  has  once  been 
acquired,  but  a  state  in  which,  from  defective  structure  of  the 
brain,  the  individual  has  never  been  able  to  acquire  any  degree 
of  intellectual  power  to  fit  him  for  his  social  position.  It  com- 
mences with  life  and  continues  through  it  (Taylor) . 

Classification  of  Insanity. — This  is  as  unsatisfactory  as  (or 
even  more  so  than)  the  definitions.  Most  of  the  classifications 
are  mystifying  and  incomprehensible  to  the  general  practitioner. 
One  of  the  most  intelligible  is  Krafft-Ebing's,  as  modified  by 
E.  D.  Fisher;  this  is  herewith  appended: 


MENTAL    DISEASES. 


695 


A.     Psychical    Disease  of  the 
Developed    Brain. 
I.  Functional  neuroses   or   dis- 
eases without  a  pathological 
basis. 

(i)    Melancholia      (inhibition 
of  mental   action). 
a.   Melancholia  simplex. 
h.    Melancholia  cum  stu- 
pore. 

(2)  Mania. 

a.   Mania  with  exalation. 
h.    Mania  with  frenzy. 

(3)  Confusional  insanity,   or 

primary    dementia. 

(4)  Stuporous  insanity. 

(5)  Secondary  dementia. 

a.  With  agitation. 

b.  With  apathy. 

II.  Psychical  degenerations' 
that  is,  diseased  conditions 
of  the  developed  brain,  in- 
herited or  acquired. 

( 1 )  Constitutional  affe  ctive 
insanity  (folic  raison- 
nante) . 

Moral  insanity. 
Impulsive  insanity. 
Transitory  mania. 

Kleptomania. 

Pyromania. 

Dipsomania. 

Homicidal  mania. 

Suicidal  mania. 

(2)  Paranoia. 

a.  Primary. 

b.  Acquired. 

I.  Typical  form 

(with   delusions 


of     persecution 
and    grandeur). 

2.  Questioning  par- 
anoia. 

3.  ReUgious  para- 
noia. 

4.  Erotic  paranoia 
(sexual  perver- 
sion) . 

(3)  Periodical  insanity — cir- 
cular insanity. 

(4)  Insanity    from     constitu- 
tional neuroses. 

a.  Neurasthenic  insanity. 

Agoraphobia. 
Claustrophobia. 
Aerophobia. 
Zoophobia. 

b.  Epileptic  insanity. 

c.  Hysterical  insanity. 

d.  Hypochondriacal     in- 
sanity. 

III.   Cerebral    disease    with    con- 
stant   pathological    changes, 
or  organic  psychoses, 
(i)   Acute  delirium. 

(2)  General  paresis    (demen- 
tia paralytica). 

(3)  Syphilitic  insanity. 

(4)  Alcoholic  insanity. 

(5)  Senile  insanity. 

B.     Arrested     Cerebral     De- 
velopment. 
(i)    Idiocy. 

a.  With  predominant  in- 
tellectual defect. 
•     b.   With       predominant 
ethical     defect      (pri- 
mary moral  weakness) . 


696  MELANCHOLIA. 

MELANCHOLIA. 

Synonyms. — Depression  of  spirits;   psychalgia. 

Definition. — A  variety  of  mental  alienation,  characterized  by 
more  or  less  profound  depression,  with  either  no  marked  intel- 
lectual disturbance  or  the  presence  of  more  or  less  incoherence, 
and  hallucinations  and  delusions.  The  cerebral  mechanism 
develops  a  condition  of  super  sensitiveness,  all  impressions  being 
exaggerated,  and  a  state  of  abnormal  self-consciousness  existing. 

Varieties. — Melancholia  simplex;  hallucinatory  melancholia, 
melancholia  agitata;  melancholia  attonita;  hypochondriac  mel- 
ancholia; chronic  melancholia;  senile  melancholia. 

Causes. — Heredity,  failing  health,  grief,  domestic  and  financial 
worries,  neurasthenia,  menstrual  irregularities,  pregnancy,  child- 
birth, lactation,  climacteric,  gastrointestinal  disorders,  alcoholic 
and  sexual  excesses,  and  organic  brain  disease  may  be  men- 
tioned as  causes.  Religion  rarely  causes  this  form  of  insanity 
although  it  frequently  lends  color  to  it.  It  is  most  frequent  in 
women  and  in  the  young.  Attacks  of  melancholia  are  more 
frequent  in  the  spring  and  early  summer  months  and  statistics 
show  that  suicides  also  are  more  frequent  during  these  periods. 

Pathology. — The  alterations  in  the  nerve-structure,  under- 
lying an  attack  of  melancholia,  are  undetermined.  Anemia 
and  sluggish  nervous  energy  are  constant  phenomena,  but  are 
hardly  the  only  conditions  disturbing  the  cortex. 

Symptoms. — Melancholia  may  be  the  initial  stage  of  a  mania, 
delusional  insanity,  or  paretic  dementia,  or  a  stage  oifolie  circu- 
laire. 

Mental.  The  cardinal  condition  is  a  feeling  of  depression, 
misery,  or  mental  anguish  or  pain,  for  which  no  adequate  cause 
may  exist.  The  onset  is  usually  gradual,  with  a  disposition 
to  neglect  duties  and  self,  the  patient  worrying  over  a  something 
he  cannot  explain.  The  world  is  dark  and  gloomy;  and  the 
patient  has  a  foreboding  of  some  awful  calamity  that  is  to  affect 
or  wreck  him  or  his  family.  Suspicion,  distrust,  and  often  fear 
of  wife,  children,  relatives,  or  friends  are  common.  Insomnia 
is  a  constant  and  stubborn  symptom.     The  memory  is  main- 


MELANCHOLIA.  697 

tained,  and  the  reasoning  faculties  are  usually  intact.  The 
patient  may  sit  quietly,  declining  or  unable  to  talk  (silent 
melancholia,  or  mutism),  or  be  restless,  according  to  the  char- 
acter of  the  emotions  affected. 

Physical.  The  patient  presents  either  an  anxious  or  a  woe- 
begone expression.  Headache,  particularly  a  post-cervical  ache, 
is  a  very  constant  symptom.  The  skin  is  dry  and  harsh,  the  res- 
pirations superficial,  the  cardiac  action  slow  and  feeble  and  there 
are  gastric  catarrh,  constipation,  and  scanty,  high-colored  urine. 
The  tongue  is  flabby  and  coated,  and  the  appetite  is  poor.  The 
refusal  to  take  food  is  most  characteristic. 

Hallucinatory  melancholia  is  an  aggravated  form  of  the  disease 
in  which  in  addition  to  the  painful  mental  reflexes,  there  are  dis- 
tressing hallucinations  and  illusions,  the  patient  living  in  a  realm 
of  terror.  The  attack  may  be  the  result  of  a  delusion,  but  much 
more  frequently  the  depression  and  foreboding  give  rise  to  the 
delusion.  The  delusions  of  melancholia  are  usually  of  self- 
accusation,  self-abasement,  and  justified  persecution;  the  patient 
feels  that  he  is  being  punished  for  some  transgression,  imaginary 
or  otherwise. 

The  manias  of  persecution  and  the  monomanias  of  suspicion 
are  all  of  a  melancholic  type,  the  result  of  painful  hallucinations. 

Hypochondriac  melancholia  shows  all  subjective  impressions 
with  disturbed  memory,  leading  to  the  belief  that  the  bowels 
have  been  removed,  food  cannot  be  digested,  that  the  brain  has 
turned  around,  that  the  blood  cannot  circulate,  and  that  gallons 
of  blood  have  been  drawn  from  the  body.  These  distressed 
individuals  are  often  conscious  of  every  organ  of  the  body  and 
experience  disagreeable  impressions  coming  from  them  all,  and 
as  a  consequence  are  irritable,  fretful,  and  exacting.  It  is  to 
be  remembered  that  not  uncommonly  these  patients  really  have 
an  organic  disease  affording  a  foundation  for  the  delusions. 

Melancholia  agitata  is  that  variety  characterized  by  continual 
agitation,  in  which  the  fearful  and  distressful  thoughts  and  im- 
aginations cause  wringing  of  the  hands,  restless  walking,  rhyth- 
mic swaying  of  the  body,  and  prayers  beseeching  help,  with 
tears  flowing  down  their  cheeks,  crying  out  for  assistance  and 


698  MELANCHOLIA. 

protection.  Incoherent  and  violent  impulses  are  frequent, 
the  excitement  often  resembling  an  attack  of  mania. 

Melancholia  attonita,  or  melancholia  with  stupor,  is  marked 
by  the  patients  seeming  to  be  overwhelmed,  sitting  mute,  mo- 
tionless, and  expressionless,  refusing  to  assist  themselves  in  any 
way,  and  often  requiring  mechanical  feeding.  Memory  is 
usually  impaired  in  this  variety,  and  attacks  of  violence  may 
occur. 

Chronic  melancholia  is  the  continuation  of  the  depression  over 
a  long  period,  the  individual  living  in  the  fear  of  impending  dan- 
ger or  punishment  for  supposed  acts,  for  long  periods  of  time, 
often  with  apparent  lucid  periods. 

Senile  melancholia  is  a  condition  of  extreme  mental  distress 
associated  with  beginning  senile  dementia. 

Suicidal  impulses  are  present  in  a  fair  proportion  of  cases  of 
melancholia,  and  unless  there  is  everlasting  vigilance  the  patient 
will  succeed  in  his  insane  desire. 

Diagnosis. — The  cases  of  simple  melancholia  are  readily  deter- 
mined. Melancholia  agitata  is  frequently  mistaken  for  acute 
mania.  Melancholia  attonita  closely  resembles  acute  dementia 
— a  condition,  it  is  but  fair  to  mention,  denied  by  many  alienists. 

Prognosis. — A  typical  attack  of  melancholia  runs  a  definite 
course,  not  unlike  the  typical  course  of  a  fever.  It  is  favorable 
in  the  mild  cases  of  all  forms  not  associated  with  organic  disease, 
and  in  those  who  have  not  reached  the  climacteric.  Delusional 
melancholia  has  the  most  unfavorable  prognosis.  Pronounced 
cases  of  melancholia  attonita  are  more  apt  to  terminate  in  de- 
mentia than  any  other  variety. 

Treatment. — Change  of  environment  and  rest  are  essential. 
Attention  to  the  gastrointestinal  canal  is  of  the  greatest  impor- 
tance, as  the  dyspepsia  and  constipation  of  melancholic  patients 
form  a  barrier  to  their  recovery.  Frequent  bathing,  with  friction 
to  the  surface,  aids  in  the  eliminative  action  of  the  skin.  The  diet 
must  be  of  the  most  nutritious  character.  If  food  is  persistently 
refused,  mechanical  feeding  must  be  practised.  The  late  Dr. 
Gray  was  a  strong  advocate  of  small  doses  of  opium,  or  morphin, 
in  acute  melancholia,  and  in  properly  selected  cases  it  is  a  most 


MANIA.  699 

valuable  agent.  Tincture  of  quebracho,  3j  to  ij  (4  to  8  gm.), 
well  diluted,  three  times  daily,  is  often  a  valuable  remedy.  If 
the  arterial  tension  is  relaxed,  good  results  follow  the  use  of 
digitalis.      Sodium  phosphate  is  often  useful. 

Many  cases  of  melancholia  seem  to  be  due  to  a  brain  fatigue 
and  if  the  patient  can  be  given  many  hours'  sleep  in  the  early 
days  of  the  attack  recovery  is  assured.  In  melancholia  attonita, 
excellent  results  often  follow  the  use  of  cannabis  indica  in  in- 
creasing doses.  Such  tonics  as  quinin,  arsenic,  and  strychnin 
are  of  value  in  building  up  the  patient  and  as  the  strength  im- 
proves open-air  exercise  must  be  employed.  Insomnia  must 
be  combated  by  evening  bathing  and  feeding  and  by  the  use 
of  chloral,  sulphonal,  trional,  or  hyoscin. 

MANIA. 

Synonyms. — Insanity;  madness. 

Definition. — An  intense  mental  exaltation,  with  great  excite- 
ment, loss  of  self-control,  with,  at  times,  absolute  incoherence 
of  speech,  and  loss  of  consciousness  and  memory    (Clouston). 

Mania  is  a  condition  characterized  by  an  abnormal  exaltation 
and  activity  of  the  mental  functions — the  intellectual  faculties, 
the  emotions,  and  the  will — and  may  show  itself  by  irrational 
talking  and  acting,  by  delusions,  illusions,  and  hallucinations, 
and  by  unusual  muscular  activity  or  movements  (Chapin). 

A  mental  condition  in  which  there  is  an  emotional  exaltation, 
accompanied  by  illusions,  hallucinations,  delusions,  great  men- 
tal and  physical  excitement,  and  a  complete  loss  of  the  inhibitory 
power  of  the  will;  in  acute  cases,  and  frequently  in  chronic 
forms  of  the  disease,  there  is  marked  destructiveness  and  a 
tendency  to  violence  (Wood). 

An  attack  of  mania  may  be  acute,  subacute,  or  chronic. 

Causes. — -Inflammation  or  other  organic  disease  of  the  brain 
or  its  membranes,  mental  shock  or  strain,  domestic,  moral,  or 
financial  worry,  excesses  of  various  kinds,  ovarian  disease, 
menstrual  disorders,  climacteric  in  neurotic  individuals,  preg- 
nancy, parturition,  lactation,  anemia,  alcoholism,  syphilis,  and 
hereditary  predisposition  are  the  most  frequent  causes. 


yoo  MANIA. 

Pathology. — There  are  no  constant  morbid  changes  associated 
with  mania.  In  all  varieties  of  acute  insanity  there  exists 
vitiated  nervous  energy  or  impaired  vitality,  the  result  of  over- 
excitement  or  overstimulation,  motor  disturbance,  or  auto- 
infection,  due  to  the  imperfect  elimination  of  the  products  of 
tissue-waste.  If  death  follows  the  acute  symptoms,  the  vessels 
of  the  brain  and  membranes  are  engorged,  but  in  the  majority 
of  instances  the  brain  structure  is  normal. 

If  death  occurs  in  chronic  mania,  the  most  frequent  change 
found  will  be  thickened  and  adherent  dura  mater.  Any  form 
of  organic  change  may  be  found  postmortem  in  those  dying  of 
any  form  of  mania. 

"  There  is  no  reason  why  mere  dynamic  brain  disturbance 
should  not  kill  and  leave  no  structural  trace,  any  more  than  that 
it  should  for  months  abolish  judgment,  affection,  and  memory, 
and  then  pass  off  and  leave  the  brain  and  all  its  functions  intact 
(Clouston). 

Symptoms.  Acute  Mania. — The  onset  may  be  abrupt,  or  fol- 
low a  period  of  emotional  depression,  associated  with  lassitude, 
feeling  of  unrest,  disinclination  to  work,  and  disorders  of  the 
gastrointestinal  canal,  with  insomnia  and  an  introspection ;  these 
symptoms  constitute  the  m^elancholic  stage  of  mania. 

The  maniacal  stage  is  characterized  by  loud  talking,  intense 
egotism,  violent  motions  of  the  limbs  and  body,  great  restless- 
ness, and  excitement;  the  thoughts  flow  with  wonderful  freedom 
and  amazing  rapidity,  the  condition  often  resembling  the  symp- 
toms of  early  alcoholic  intoxication;  as  the  exaltation  continues 
the  patient  becomes  either  sullen,  irritable,  and  angry,  offering 
violence  to  those  around  him,  or  he  becomes  garrulous,  talking 
of  his  personal  affairs,  is  confidential  and  communicative  to 
strangers,  often  making  egotistic  offers,  passing  frequently  into 
incoherence  of  language  and  action.  Sexual  passions  are  fre- 
quently exalted  and  acts  of  masturbation  practised,  with  out- 
breaks of  vulgar,  obscene,  and  profane  language,  which  is 
entirely  foreign  to  the  individual  in  mental  health.  Delusions 
are  an  almost  constant  symptom,  of  a  superficial  or  transitory 
character,  changing  with  every  new  appearing  mood.     The  mani- 


/  MANIA.  701 

acal  patient  is  sleepless,  or  may  have  short  naps,  at  once  con- 
tinuing his   chatter   on   awakening. 

Any  attack  may  show  all  of  the  symptoms  mentioned,  or  any 
one  or  more  of  them,  but  the  great  majority  of  cases  show  intense 
egotism,  loud  talking,  violent  motion  of  limbs  or  body,  hurry,  ex- 
citem^ent,  insoinnia,  incoherence,  and  incessant  noise. 

The  course  of  an  attack  shows  periods  of  remissions  and  ex- 
acerbations with  nocturnal  crises ;  loss  of  flesh  and  mental  weak- 
ness are  often  marked  as  the  attack  progresses. 

Acute  delirious  mania,  typhomania,  is  a  psychosis  of  sudden 
onset,  attended  with  increased  bodily  temperature,  dry  tongue, 
quick,  feeble  pulse,  scanty  urine,  and  marked  by  delirium  with 
sensuous  hallucinations,  marked  incoherence,  restlessness,  refusal 
of  food,  loss  of  memory,  and  rapid  bodily  wasting,  terminating 
frequently  in  death. 

Amenorrheal  mania  consists  of  attacks  of  mania  occurring  at 
the  menstural  epoch.  Homicidal,  suicidal,  and  various  hysteric 
impulses  are  frequent. 

Mania-a-potu  is  an  attack  of  acute  delirium,  due  to  alcoholic 
excesses  in  those  engaged  in  a  sudden  debauch,  or  who  have 
drunk  heavily  and  eaten  little,  for  a  comparatively  short 
period. 

Asthenic  mania  is  that  form  in  which  there  is  general  anemia 
associated  with  neurasthenic  symptoms. 

Dancing  mania  is  an  hysteric  mental  state  in  which,  through 
sympathy  and  imitation,  dancing  of  a  most  grotesque  and  extrav- 
agant character  occurs.     It  is  usually  epidemic. 

Delusional  mania  is  the  result  of  fixed  delusions,  either  caus- 
ing or  associated  with,  the  maniacal  outbreak. 

Erotic  mania,  erotomania,  presents  systematized  delusions 
of  an  erotic  character,  not  necessarily  accompanied  by  sexual 
desire. 

Nymphomania  is  a  morbid,  irresistible  impulse  to  satisfy  the 
sexual  appetite,  and  is  peculiar  to  the  female  sex. 

Epileptic  mania  follows  an  epileptic  paroxysm,  and  is  often  of 
a  most  violent  kind,  the  maniacal  acts  being  of  the  most  treach- 
erous and  malicious  character. 


702  MANIA. 

Hallucinatory  mania  presents  visual,  auditory,  olfactory,  and 
other  sense  hallucinations. 

Homicidal  mania  is  any  variety  of  mental  disease  in  which 
there  is  a  desire  or  an  attempt  on  the  part  of  the  patient  to  com- 
mit murder.  The  condition  may  be  the  result  of  delusions 
that  the  persons  attacked  either  are  persecuting  or  going  to 
kill  the  patient,  or  of  the  excessive  excitement  that  vents  itself 
in  destructiveness,  combativeness,  or  desire  to  kill;  or  there  may 
be  a  morbid  desire,  impulse,  or  craving  to  do  murder;  or  the 
homicidal  act  may  be  unconsciously  done  during  an  acute  de- 
lirium, or  a  paretic  or  epileptic  maniacal  impulse.  In  cases  of 
murder  the  question  of  responsibility,  or  the  difference  between 
the  insane  criminal  and  the  criminal  is  not  always  readily  deter- 
mined. With  insane  criminals,  in  the  act  itself  lies  the  satisfac- 
tion and  not  the  object,  while  with  criminals  the  act  is  only  a 
means  to  an  end;  to  the  former,  crime  is  a  pleasure,  to  the  later 
a  paying  business,  necessitating,  it  may  be,  disagreeable  or  hor- 
rible acts. 

M orpkinom-ania  is  the  insane  craving  for  the  stimulating  ac- 
tion of  morphin — a  moral  insanity. 

Puerperal  mania  is  the  maniacal  outbreak  as  seen  in  the  puer- 
peral woman.  This  is  now  thought  to  be  of  separate  origin,  al- 
though the  mental  strain  through  which  the  female  has  been 
passing  is  a  predisposing  factor  in  those  who  have  a  neurotic 
history. 

Transitory  mania,  or  ephemeral  mania,  is  a  rare  form  of  mani- 
acal excitement  of  sudden  onset,  violent  and  decided  in  charact- 
er, accompanied  by  great  insomnia,  incoherence,  and  more  or  less 
complete  unconsciousness  of  familiar  surroundings.  The  attack 
as  suddenly  terminates,  the  duration  being  from  a  few  hours  to 
a  few  days. 

Senile  mania  is  the  mental  exaltation  occurring  in  persons  with 
senile  arterial  changes  or  senile  cerebral  atrophy.  It  is  soon 
followed' by  dementia. 

Recurrent  mania,  or  chronic  mania  with  lucid  intervals  of 
Iqjiger  or  shorter  duration.  This  is  generally  of  alcoholic 
origin. 


MANIA.  703 

A  maniacal  outbreak  may  present  any  one  or  a  number  of  the 
varieties  named. 

Chronic  Mania. — A  condition  of  continual  mental  exaltation, 
the  acute  symptoms  having  continued  in  a  chronic  course.  The 
line  that  distinguishes  between  an  acute  and  a  chronic  mania  must 
always  be  somewhat  arbitrary  and  unscientific.  The  duration  of 
the  mania  beyond  twelve  months  is  usually  considered  sufficient 
to  determine  the  condition,  and  this  is  well,  since  it  precludes  the 
possibility  of  terming  the  condition  incurable.  If  the  term 
chronic  mania  was  restricted  to  those  cases  in  which,  between 
the  exacerbations  of  restlessness,  excitement,  and  destructive- 
ness,  were  evidences  of  dementia,  less  confusion  would  occur. 

Terminations  of  Mania. — About  50  per  cent,  of  acute  manias, 
not  due  to  organic  disease,  recover  after  periods  varying  from 
one  month  to  several  years.  A  fair  proportion  of  cases  make  a 
partial  recovery  and  are  able  to  return  to  their  work,  but  always 
showing  some  alteration  in  character  or  affection,  or  some  eccen- 
tricity, or  a  slight  mental  weakness.  About  20  per  cent,  of  cases 
terminate  in  dementia  or  mental  death  and  this  is  always  the 
fear  in  each  case.  Two  per  cent,  of  cases  die,  either  the  result  of 
exhaustion  or  from  the  organic  condition  causing  or  associated 
with  the  attack. 

Prognosis. — The  question 'of  recovery,  partial  or  complete,  is 
always  difficult  to  determine,  depending  upon  the  cause,  tem- 
perament, disposition,  education,  nationality,  and  the  normal 
mentality  of  the  individual.  Recovery  is  usually  gradual; 
rarely  sudden  restoration  occurs. 

Favorable  indications  are:  Sudden  onset,  short  duration, 
youth  of  patient,  absence  of  fixed  delusions,  good  appetite, 
increasing  hours  of  sleep;  moderate  or  no  increase  in  tempera- 
ture, pulse,  and  respiration;  no  evidences  of  mental  weakness, 
no  paralysis  or  alteration  of  pupils  or  articulation,  no  epilepsy, 
no  unconsciousness  to  the  calls  of  nature,  and  no  former  attacks. 
Unfavorable  indications  are  the  opposite  of  these,  the  presence 
of  organic  brain  disease,  a  strong  hereditary  tendency,  and  the 
possession  of  an  excitable  disposition  or  nervous  diathesis. 

Treatment. — The  indications  for  treatment  are  to  quiet  the 


704  MANIA. 

exalted  mentality  and  to  promote  the  constructive  metamor- 
phosis. Every  means  should  be  used  to  lessen  the  excitement 
of  the  patient  and  produce  refreshing  sleep.  A  hot  or  warm 
bath  is  frequently  one  of  the  most  soothing  means  of  reducing 
excitement;  changing  the  environment  of  the  patient  and  plac- 
ing him  under  the  care  of  a  good,  firm,  but  kind  and  intelligent 
nurse  is  of  importance ;  the  society  of  the  family  or  friends  must 
be  forbidden,  for  visits  act  as  stimulants  to  the  disordered 
intellect  and  encoura'ge  discussion  on  the  part  of  the  patient  as 
to  the  character  of  the  treatment,  and  thus  reduce  the  discipline 
so  essential  to  early  recovery. 

If  means  of  this  character  are  unavailing,  and,  unfortunately, 
in  the  majority  of  attacks  they  will  be,  then  resort  must  be  had 
to  sedatives,  for  every  day's  continuance  of  the  maniacal  out- 
breaks lessens  the  chances  of  restoration.  Hyoscin  hydrobro- 
mid,  gr.  1/120  to  1/60  (0.00032  to  o.ooi  gm.),  repeated  two  or 
three  times  daily,  watching  its  effect  on  the  pupils;  sulphonal, 
gr.  XX  (1.3  gm.),  repeated  with  caution;  chloralamid,  gr.  xxx  to 
xl  (2  to  2.6  gm.),  repeated  three  or  four  times  daily;  and  trional, 
gr.  xxx  (2  gm.),  repeated  in  two  or  four  hours,  are  of  great  value 
in  this  connection.  The  latter  is  one  of  the  most  reliable  drugs 
for  relieving  maniacal  excitement  and  insomnia .  Tincture  of  pa  s  - 
sion  flower  (passifiora  incarnata),  3i  to  3ii  (4  to  8  c.c),  several 
times  daily,  may  also  be  used.  When  there  is  much  excitement 
and  the  pulse  is  weak,  full  doses  of  the  bromids  and  digitalis 
are  of  benefit.  If  the  muscular  excitement  is  pronounced,, 
good  results  follow  the  use  of  morphin  sulphate,  hypoder- 
mically,  alone  or  combined  with  either  atrophin  sulphate, 
hyoscin  hydrobromid,  or  duboisin  sulphate. 

In  attacks  of  acute  mania  with  flushed  face,  throbbing  arteries, 
full  pulse,  and  delirious  cxcitment,  fiuidextract  of  gelsemium, 
ni^ii  (0.12  c.c),  every  hour  until  dilatation  of  the  pupils  and 
ptosis  develop  or  until  improvement  occurs,  is  indicated.  Tinc- 
ture of  veratrum  viride,  tt^x  (0.65  c.c),  is  also  useful  under  such 
circumstances. 

Ice  or  cold  to  the  head  is  likewise  beneficial  in  cases  with 
flushed  face  and  throbbing  temporals.     Post-epileptic    excite- 


EPILEPTIC    INSANITY.  705 

ment  is  best  controlled  by  large  doses  of  chloral  given  by  mouth 
or  rectum. 

The  general  condition  of  the  patient  calls  for  the  most  prompt 
and  efBcient  treatment.  Attention  to  the  gastrointestinal  canal 
and  kidneys  is  of  paramount  importance,  as  many  attacks  of 
mania  are  the  result  of  autointoxication  from  the  retention  of 
the  products  of  mal-assimilation  and  tissue-waste.  The  diet 
should  be  of  the  most  nutritious  character,  peptonized  or  hot 
milk,  hot  broths,  eggs,  and  often  alcoholic  or  malt  liquors, 
administered  at  frequent  intervals. 

Patients  not  infrequently  refuse  food  on  account  of  lack  of 
appetite,  abhorrence  of  food,  or  from  fear  of  poisoning,  when 
recourse  must  be  had  to  the  naso-stomachic  tube,  or  nutritive 
enemata.  If  the  breath  be  heavy,  the  tongue  badly  coated,  the 
bowels  costive,  and  the  skin  sallow,  the  very  best  results  follow 
washing  out  the  stomach,  providing  the  maniacal  condition  per- 
mits. Tonics  are  of  great  value,  a  combination  like  the  following 
always  being  beneficial: 

I^.     Quininae  sulphat gr.  xlviij  3 .  i       gm. 

Strychninse  sulphat gr.  ss  .032  gm. 

Acid,  hydrochlor.  dil.  .  .  .    f  5iij  12  .  c.c. 

Aquae  chloroformi f  Biij  90.  c.c. 

Aquae  menthaB  pip. q.s.  ad  f§vj        ad  180.         c.c. 
M.  S. — Dessertspoonful,  diluted,  every  four  or  six  hours. 

The  question  of  removal  to  a  hospital  for  the  insane  arises 
in  nearly  all  cases,  and  should  probably  be  answered,  in  the 
vast  majority  of  instances,  in  the  affirmative;  as  the  discipline, 
regular  hours,  and  order  of  a  well-managed  hospital  for  the 
insane  have  a  most  remarkable  effect  on  the  majority  of  patients. 

EPILEPTIC  INSANITY. 

Definition. — A  mental  condition  caused  by,  or  the  result  of, 
epilepsy. 

Causes. — The  careful  study  of  the  brain  of  those  having  epilep- 
tic insanity  has  failed  to  determine  why  some  epileptics  suffer 

45 


7o6  EPILEPTIC   INSANITY. 

from  any  of  the  insanities  and  others  have  their  normal  mental- 
ity, and  yet  others  are  better  after  a  convulsion. 

Varieties. — Pre-epileptic  mania;  post-epileptic  mania;  demen- 
tia epileptica;  imbecility  with  epilepsy. 

Symptoms. — The  mental  changes  constituting  epileptic  in- 
sanity, save  in  the  cases  of  epilepsy  with  imbecility  or 
idiocy,  develop  after  some  years  of  the  ordinary  epileptic 
paroxysms. 

Pre-epileptic  mania  consists  in  attacks  of  mania  some  days  or 
hours  preceding  the  epileptic  convulsion.  The  patient  is  mo- 
rose, irritable,  and  threatening,  often  making  homicidal  attacks 
on  those  around  him,  friends  or  foes.  Rarely  the  epileptic 
seizure  is  replaced  by  various  insane  or  so-called  hysteric  acts, 
as  fits  of  dancing,  laughing,  crying,  screaming,  swearing,  or 
scolding. 

Post-epileptic  mania  follows  the  epileptic  paroxysm,  either 
taking  the  place  of  the  comatose  state  or  following  it.  The 
maniacal  acts  during  these  outbreaks  are  often  of  the  most 
desperate  and  impulsive  character,  many  an  asylum  physician 
and  attendant  carrying  scars  the  result  of  attacks  of  post-epileptic 
maniacs. 

Epileptic  dementia  is  the  terminal  mental  obliquity  resulting 
in  about  30  per  cent,  of  insane  epileptics  who  do  not  succumb 
previously  to  nephritis  or  tuberculosis. 

Epileptic  imbecility  is  a  congenital  condition  in  which  epi- 
lepsy and  imbecility  are  associated. 

Prognosis. — The  great  majority  of  persons  suffering  from 
epileptic  insanity  develop,  sooner  or  later,  either  nephritis  or 
tuberculosis.  Recovery  from  epileptic  mania  is  a  rare  occur- 
rence. Thirty  per  cent,  of  epileptic  maniacs  progress  to  demen- 
tia in  from  five  to  ten  years. 

Treatment. — There  is  no  doubt  but  that  full  doses  of  the  bro- 
mids  lessen  the  severity  and  frequency  of  the  paroxysms.  If 
the  attack  can  be  anticipated,  it  may  sometimes  be  averted  by 
an  enema  of  chloral,  gr.  xx  to  xxx  (1.3  to  2  gm.),  or  chloralamid, 
gr.  xl  to  Ix  (2.6  to  4  gm.),  or  amyl  nitrite,  tt^v  (0.3  c.c),  by  in- 
halation or  by  mouth.     For  the  condition  of  status  epilepticus 


CIRCULAR   INSANITY.  707 

the  following  combination,  alternated  with  saline  purgatives, 
has  given  good  results: 

I^.      Chloral gr.  xx  1.3  gm. 

Tinct.  cannab.  indicae.  .  .    ri\xv  i  .     c.c. 

Inf.  digitalis f  §j  30.     c.c. 

M.  S. — Administer  by  enema  every  three  or  four  hours. 

The  use  of  opium  for  a  long  period  has  been  known  to  break 
up  recurrent  maniacal  attacks. 

The  general  condition  of  the  patient  must  receive  careful  at- 
tention, as  there  is  a  strong  tendency  to  the  development  of 
nephritis,  tuberculosis,  and  gastric  catarrh.  These  patients 
are  great  feeders — often  gluttons — and  are  sure  to  eat  more 
than  they  can  properly  assimilate.  Free  action  of  the  bowels 
and  kidneys  must  be  promoted. 

Never  contradict,  or  attempt  to  reason  with,  an  epileptic 
during  the  period  of  excitement. 

CIRCULAR  INSANITY. 

Synonym. — Folic  circulaire. 

Definition. — A  mental  disease  characterized  by  regularly 
alternating  and  recurring  periods  of  mental  exaltation,  depres- 
sion, and  semilucidity 

Causes. — Hereditary  predisposition.  The  exciting  causes  are 
any  of  those  conditions  which  depress  the  brain  or  general 
system. 

Pathology. — There  is  no  characteristic  lesion  associated  with 
circular  insanity. 

Symptoms. — It  is  essentially  a  chronic  condition  and  probably 
incurable.  The  disease  usually  begins  as  a  melancholia,  the  de- 
pression being  an  apathy  and  torpor  rather  than  a  mental  pain, 
and  suicidal  feelings  and  impulses  are  rare.  This  condition  is 
soon  succeeded  by  mania,  a  mental  exaltation  with  hyperes- 
thesia and  exaggeration  of  nervous  functions,  the  reasoning 
power  well  retained ;  this  is  in  turn  followed  by  a  semilucid  inter- 
val,  often  giving  promise  of  recovery,   to  be  sooner  or  later 


7o8  KATATONIA. 

followed  by  another  cycle.  These  periods  follow  each  other 
with  remarkable  regularity,  each  being  of  the  same  duration. 
Rarely  the  various  periods  are  of  irregular  duration. 

The  general  health  is  well  maintained,  the  patient  gaining  in 
flesh  during  the  stages  of  depression  and  lucidity  and  losing 
during  the  period  of  exaltation. 

Diagnosis. — The  regularity  of  the  different  periods  soon  estab- 
lishes the  diagnosis. 

Prognosis. — Incurable.  The  affection  ends  in  dementia  after 
a  lapse  of  several  years. 

Treatment. — Attention  to  the  general  health  and  meeting  the 
symptoms  of  the  different  periods  as  they  recur  constitutes  the 
treatment.  No  means  are  known  to  prevent  the  recurrence  of 
the  periods. 

KATATONIA. 

Synonyms. — Alternating  insanity;   Kahlbaum's  insanity. 

Definition. — A  mental  disease  characterized  by  irregular 
cyclical  symptoms,  ranging  from  melancholia  to  mania,  followed 
by  stupidity  and  confusion,  with  cataleptoid  phenomena,  in 
turn  followed  by  lucidity  for  a  time,  recovery,  or  dementia. 

Causes. — Hereditary  predisposition.  The  exciting  causes  are 
usually  the  results  of  some  excess.  Rarely  it  is  associated  with 
organic  brain  disease. 

Pathology. — No  characteristic  lesions  have  been  found  asso- 
ciated with  katatonia. 

Symptoms. — A  typical  case  begins  as  a  melancholia,  the  men- 
tal depression,  uneasiness,  and  distress  followed  after  a  variable 
period  by  mania,  associated  with  hallucinations  and  delusions. 
This  period  is  followed  in  turn  by  a  condition  of  attonita,  or 
rigidity  and  immobility,  or  a  cataleptoid  paroxysm.  Any  of  the 
stages  may  be  followed  by  confusional  symptoms,  or  a  true 
dementia  may  develop.  During  the  maniacal  stage  there  is  a 
tendency,  in  many  cases,  to  histrionic  and  sermon-like  declama- 
tion, or  the  speech  may  be  of  the  verbigeration  character — 
that  noisy,  incoherent,  and  meaningless  speech  seen  in  many 


DELUSIONAL    INSANITY.  709 

manias,  composed  largely  of  the  constant  repetition  of  a  few 
words  or  phrases  without  sense  or  sequence  (onomatomania) . 

During  the  stage  of  attonita  the  presence  of  the  so-called  mu- 
tism, or  mutacismus,  sl  pathologic  tendency  to  be  silent,  may  con- 
tinue for  days,  weeks,  or  months,  or  it  may  be  interrupted  by  pe- 
riods of  verbigeration. 

The  immobility  or  rigidity  so  characteristic  of  a  period  of  kata- 
tonia  is  frequently  alternated  with  automatic,  incessant,  and 
monotonous  movements — the  stereotyped  movements. 

Patients  suffering  from  katatonia  often  refuse  food  for  days  at 
a  time  and  then  suddenly  present  symptoms  of  boulimia.  Vaso- 
motor and  trophic  changes  are  frequent,  one  of  the  most  constant 
being  cyanosis  of  the  hands  and  other  peripheral  parts.  Hema- 
toma auris,  insane  ear,  or  perichondritis  auriculas,  is  frequent. 
Epileptiform  attacks  may  usher  in  the  disease  or  occur  during 
any  of  its  stages. 

Diagnosis. — It  may  be  diagnosed  as  melancholia,  mania,  or  a 
dementia,  depending  upon  which  part  of  the  cycle  is  first  ob- 
served, but  after  being  under  observation  long  enough  to  note 
a  complete  cycle  the  diagnosis  is  readily  determined.  Katatonia 
differs  from  circular  insanity  in  the  presence  of  the  stage  of 
attonita  and  catalepsy. 

Prognosis. — The  disease  may  continue  for  a  number  of  years 
and  recovery  follow,  but  as  a  rule  the  prognosis  is  unfavorable. 

Treatment.— This  consists  in  attention  to  the  general  condi- 
tion, and  combating  the  various  symptoms  as  they  arise.  In 
cases  associated  with  anemia,  arsenic,  and  strychnin  seem  to  be 
valuable  When  food  is  refused  by  the  insane,  and  stomach  or 
nasal  tube  or  rectal  feeding  is  necessary,  the  stage  of  food  refusal 
is  often  wonderfully  shortened  by  adding  sulphonal,  gr.  x  to  xv 
(0.6  to  I  gm.),  to  each  feeding. 

DELUSIONAL  INSANITY. 

Synonyms. — Delusional  mania;  delusional  melancholia;  pri- 
mary delusional  insanity. 

Definition. — A  mental  state,  with  fixed  or  partly  systema- 
tized delusions,  associated  with  either  brain  exaltation  or  excite- 


7lO  DELUSIONAL   INSANITY. 

merit  without  maniacal  acts,  or  a  mental  depression,  minus  the 
somatic  symptoms  of  melancholia. 

An  insane  delusion  is  a  false  belief  for  which  there  is,  or  may 
be,  no  reasonable  foundation  and  which  would  be  incredible 
under  the  given  circumstances  to  the  same  person  if  of  sound 
mind,  and  concerning  which  his  mind  is  not  open  to  permanent 
correction  through  evidence  or  argument. 

Causes. — Cerebral  and  bodily  exhaustion,  the  result  of  over- 
work, neglect  of  personal  hygiene,  or  alcohol,  tobacco,  drug  or 
sexual  excesses,  impairment  of  the  nerve-centers  consequent  to 
fevers  or  shock,  the  climacteric  period,  worry,  and  insufficient 
food  are  the  most  common  causes. 

Pathology. — The  affection  runs  a  subacute  or  chronic  course 
and  seldom  ends  directly  in  death,  usually  being  terminated  by 
some  intercurrent  organic  disease.  In  the  few  cases  in  which 
post-mortem  examinations  have  been  made,  the  vessels  of  the 
brain  were  found  torpid  or  dilated,  due  in  all  probability  to  a 
vasomotor  paresis  which  gave  rise  during  life  to  an  imperfect 
cerebral  circulation. 

Symptoms. — Either  following  an  attack  of  acute  mania  or 
melancholia,  but  more  commonly  without  either  of  these  condi- 
tions, occurs  a  set  delusion  or  delusions,  which,  to  the  patient, 
are  so  real  that  no  amount  of  argument  can  dispel  his  or  her 
belief  in  them.  These  cases  are  often  classed  as  manias  or 
melancholias,  but,  as  they  do  not  run  the  ordinary  course  of 
either  of  these  conditions,  they  are  best  classed  clinically  by 
themselves.  The  acuteness  or  subacuteness  of  the  attack  dis- 
tinguishes them  from  paranoia.  Among  the  almost  endless 
variety  of  delusions  mention  will  be  made  of  a  few  that  have 
come  under  recent  notice:  "A  young  man  of  twenty  believes 
that  he  is  President;  another  patient,  a  driver,  believed  for  ten 
months  that  he  was  the  owner  of  a  thousand  horses,  any  one  of 
which  was  worth  thousands  of  dollars;  he  made  a  perfect  re- 
covery and  now  laughs  at  his  old  delusions.  A  young  man 
of  twenty-five  believes  his  mother  is  not  his  mother,  but  the 
woman  with  whom  he  boarded,  and  that  his  brothers  and  sisters 
are  her  children  but  no  relation  to  him.     A  young  woman  of 


DELUSIONAL    INSANITY.  7 II 

thirty  believes  she  is  pregnant  by  a  prominent  merchant;  the 
fact  being  she  is  not  and  never  has  been  pregnant."  The 
majority  of  the  delusions  are  of  an  egotistic  character,  but  lack 
the  conduct  or  appearance  of  the  position  due  to  the  character 
of  the  delusion.  A  patient  with  ragged  clothing  will  assure  you 
that  he  is  worth  millions,  and  yet  sees  nothing  inconsistent  be- 
tween his  delusions  and  his  personal  appearance.  Another  will 
assure  you  of  his  vast  business  interests,  and  yet  remains 
contented  in  the  hospital  wards,  laboring  faithfully  in  the  kit- 
chen or  laundry.  A  woman  assures  you  that  she  is  the  great 
Patti,  receiving  thousands  of  dollars  for  each  operatic  perform- 
ance, and  yet  is  apparently  happy  in  the  sewing-room. 

An  hallucination  is  an  imperfect  perception  through  any  one 
of  the  senses.  A  person  who  imagines  that  he  sees  something, 
or  hears  something,  or  tastes  something,  or  feels  or  smells  some- 
thing that  he  is  not  seeing,  hearing,  tasting,  feeling,  or  smelling, 
has  an  hallucination. 

Delusional  insanity  is  often  based  upon  the  development  of 
hallucinations  of  the  special  senses,  that  of  hearing  being  the 
most  frequent;  patients  hear  "voices"  telling  them  what  to  do 
or  not  to  do,  and  a  delusion  is  built  up  and  developed.  Again, 
"voices"  upbraid  them  or  charge  them  with  various  acts,  and 
upon  this  is  developed  a  persecutory  delusion  that  causes  them 
much  unrest. 

Again,  visions  appear,  which  result  in  delusions  of  personal 
importance.  Taste  and  smell  may  be  perverted,  causing  pro- 
longed fasting,  often  from  fear  of  poisoning. 

Diagnosis. — Delusional  mania  and  delusional  melancholia  are 
confounded  with  delusional  insanity,  the  points  of  distinction 
being  the  absence  of  severe  maniacal  and  melancholic  acts;  the 
patient  simply  possesses  his  insane  delusion  and  may  never 
refer  to  it  unless  questioned. 

Paranoia  or  monomania  and  delusional  insanity  have  many 
symptoms  in  common,  but  in  the  former  "  their  whole  thoughts 
and  lives  show  a  strong  self-consciousness,  and  their  egotism  is 
intense"  (Chapin) ;  and  if  the  patient  believes  he  is  Christ,  he 
wishes  to  be  so  respected,  and  considers  himself  wronged  if  not 


712  PARANOIA. 

SO  treated,  while  the  delusional  patient  will  say  he  is  Christ  and 
immediately  drop  the  subject.  There  are,  however,  many 
borderland  cases  in  which  the  diagnosis  is  difficult. 

The  distinction  made  here  between  paranoia  and  primary 
delusional  insanity  is  not  generally  accepted. 

Prognosis. — In  acute  primary  delusional  insanity,  recovery 
is  frequent,  although  the  delusions  may  exist  for  a  number  of 
years.  Many  patients  who  make  a  complete  recovery  will  still 
believe  that  their  delusions  were  facts.  A  fair  proportion  of  cases 
pass  into  the  condition  of  chronic  delusional  insanity, 

Treatment. — A  supportive  plan  of  treatment,  with  thorough 
action  upon  the  bowels,  kidneys,  and  skin,  and  plenty  of  fresh 
air,  is  of  great  value  in  all  cases  of  delusional  insanity.  If  the 
disease  is  the  result  of  excesses,  a  course  of  strychnin  and  arsenic 
is  indicated.  A  tranquil  condition  of  the  brain  is  essential,  and 
few  combinations  are  so  valuable  as  digitalis  and  hyoscin,  in 
small  repeated  doses.  Insomnia  is  an  annoying  symptom  in 
many  cases,  and  is  best  overcome  by  a  digestible  meal  at  bed- 
time, or  a  warm  or  hot  bath  in  the  evening,  and  if  these  fail  a 
full  dose  of  somnal,  well  diluted,  or  trional,  gr.  xxx  (2  gm,),  an 
hour  before  bedtime,  in  milk  or  spirits  should  be  administered. 

The  following  is  of  value : 

I^.      Somnal 5iii  12 .  c.c. 

Glycerin §ss  16.  c.c. 

Tr.  cardamom,  comp.  .  .  .    oss  16.  c.c. 

Aq.  menth.  pip.,  .q.  s.  ad    Biii  90.  c.c. 

M.  S. — Half  tablespoonful,  repeated  in  two  hours. 

PARANOIA. 

Synonyms. — Monomania;  chronic  delusional  insanity;  reason- 
ing mania. 

Definition. — A  chronic  mental  disease  characterized  by  fixed 
logic  or  systematized  delusions  of  persecution,  of  unseen  or  im- 
possible agencies,  or  of  self-exaltation,  the  emotions  and  mem- 
ory being  only  paroxysmally  defective,  while  the  life  of  the  in- 
dividual is  dominated  by  the  delusions. 


PARANOIA.  713 

The  term  paranoia  is  now  commonly  used  to  cover  a  group  of 
insanities  which  are  degenerative  in  origin,  chronic  in  course, 
and  characterized  by  systematized  delusions,  with  little  im- 
pairment of  the  emotional  faculties,  and  is  not  generally  accepted 
as  a  synonym  for  monomania. 

Causes. — -There  is  generally  a  hereditary  predisposition  to  in- 
sanity in  monomania  or  paranoia.  The  exciting  cause  may  be 
the  result  of  an  acute  mania  or  melancholia,  or  the  result  of  alco- 
holism, or  of  malnutrition  in  those  who  have  had  a  struggle  to 
keep  their  position  in  the  world.  Extreme  worry  in  individuals 
with  mental  instability  is  a  common  cause.  It  may  follow 
primary  or  acute  delusional  insanity. 

Symptoms. — The  cause  of  monomania  is  essentially  chronic, 
the  delusions  becoming  fixed  upon  one  particular  subject,  or  set 
of  subjects,  which  in  turn  dominate  the  life  of  the  individual. 
The  most  common  characters  of  these  systematized  delusions 
are  delusions  of  persecution  or  suspicion,  delusions  of  exaltation 
or  grandeur,  or  of  pride,  and  delusions  of  unseen  agents  or 
influences. 

The  range  which  the  delusions  of  monomania  assume  is  most 
wide  and  varied,  but  always  associated  with  the  ego.  The  pa- 
tient is  being  persecuted  not  because,  as  in  melancholia,  he 
has  committed  some  sin,  or  thinks  he  has,  and  deserves  punish- 
ment, but  because  the  persecutors  wish  to  deprive  him  of  his 
rights,  titles,  or  estate,  or  degrade  him,  or  in  some  way  injure  him. 

Diagnosis. — In  the  diagnosis  of  monomania  there  are  three 
points  to  keep  in  mind:  First,  the  duration — the  fixed,  sys- 
tematized delusions  must  have  existed  over  one  year;  second, 
the  absence  of  symptoms  of  mania  or  melancholia;  and  third, 
the  presence  of  systematized  delusions  affecting  the  personnel  of 
the  individual. 

Prognosis. — Monomania  is  an  incurable  disease.  Unless  tu- 
berculosis develops  within  a  few  years,  dementia  results. 

Treatment. — The  various  methods  adopted  for  building  up 
and  maintaining  the  tone  of  the  body  are  applicable  in  this 
affection.  The  symptoms  should  be  combated,  as  they  arise,  on 
general  therapeutic  principles. 


714  GENERAL   PARALYSIS. 

GENERAL  PARALYSIS. 

Synonyms. — General  paresis;  general  paralysis  of  the  insane; 
paresis;  paretic  dementia. 

Definition. — A  subacute  or  chronic,  degenerative  disease  of 
the  brain,  sometimes  involving  the  spinal  cord,  characterized  by 
alterations  in  the  intellectual  and  moral  character,  with  the 
development  of  unsystematized  ideas  of  self  importance  or 
delusions  of  grandeur,  finally  merging  into  dementia  (preceded 
by  either  a  mania  or  a  melancholia),  and  the  gradual  develop- 
ment of  tremor,  slurring  speech,  pupillary  changes,  ataxia, 
trophic  changes,  and  finally  general  paresis. 

Causes. — General  paralysis  of  the  insane  occurs  chiefly  be- 
tween thirty  and  fifty-five  years  of  age,  and  in  the  male  more 
frequently  than  in  the  female,  although  a  notable  increase  in 
the  lower  class  of  females  is  being  observed.  It  usually  affects 
the  robust,  middle-aged  individual,  rapidly  destroying  all  in- 
telligence and  judgment,  leaving  him  to  exist,  often  for  months, 
as  a  demented  human  automaton.  General  paresis  is  increas- 
ing, and  someone  has  said  that  its  increase  is  in  proportion  to 
"  syphilization  and  civilization." 

Predisposing  causes:  Heredity;  an  ambitious  overstraining  for 
prominence,  learning,  or  wealth;  forced  intellectual  activity  in 
those  with  imperfect  or  improper  early  training ;  or  in  those  with 
an  imperfectly  developed  or  organized  cortex;  cranial  in- 
juries; and  atheroma. 

Exciting  causes:  Alcoholic  and  sexual  excesses;  syphilis;  men- 
tal and  physical  overstrain;  and  worry. 

Pathologic  Anatomy. — A  condensed  description  of  the  path- 
ologic basis  of  general  paralysis  is  difficult.  It  may  be  described 
as  a  chronic,  diffuse,  cortical  encephalitis.  The  microscopic 
changes  in  the  cortex,  according  to  Mendel,  as  quoted  by  Folsom 
are  as  follows : 

I.  Increase  of  nuclei  and  new  cell-formation  are  observed, 
some  nuclei  small,  some  large,  and  with  such  varying  reactions 
to  coloring  agents  as  to  suggest  dissimilarity  of  origin.  The 
stellate  or  "spider"  cells  are  increased  in  the  upper  layer  of  the 


GENERAL   PARALYSIS.  715 

cortex,  where  some  may  be  normally  found,  and  extend  to  lower 
layers,  as  is  not  the  case  in  normal  brains;  they,  too,  may  be 
several  times  the  usual  size  and  also  push  through  the  white 
substance  to  the  ependyma  of  the  ventricles.  Proliferation  of 
neuroglia  or  connective  tissue,  and  in  time  sclerosis  of  the  cortex 
which  involves  the  medullary  substance  also  in  a  greater  or  less 
degree  is  common. 

2.  The  larger  blood-vessels  may  or  may  not  be  atheromatous; 
in  the  capillaries  there  is  an  increase  of  nuclei  in  the  walls,  with 
thickening  and  hyaloid  degeneration. 

3.  In  the  nerve-cells,  the  ganglion-cells,  there  are  granular  and 
fatty  degeneration  of  protoplasm,  sclerosis,  and  atrophy. 

4.  Atrophy  and  final  disappearance  of  the  nerve-fibers  is  ob- 
served, not  limited  to  the  cortex.  This  condition  is  found  in 
other  brain  diseases  also — senile  dementia  and  epilepsy,  for 
instance. 

5.  Focal  lesions  of  the  most  various  kinds,  degenerative 
changes  in  the  spinal  cord,  the  several  forms  of  sclerosis,  and 
myelitis  are  encountered. 

The  spinal  cord  undergoes  atrophy  with  gray  degeneration  in 
posterior  and  postero-median  columns,  and  in  the  posterior 
spinal  nerve-roots. 

Symptoms. — For  clinical  convenience  the  disease  is  divided 
into  three  stages — prodromal,  maniacal,  rarely  melancholic,  and 
the  stage  of  dementia — although  there  is  seldom  a  marked 
division  between  the  stages. 

The  prodromal  stage  may  exist  unrecognized  for  months  or 
longer.  It  begins  by  an  alteration  in  the  habits  and  character 
of  the  individual,  such  as  spells  of  irritability  and  obstinacy, 
which  will  not  admit  of  contradiction  or  opposition,  and  there 
is  a  general  feeling  of  elation  and  hien-etre,  or  egotism,  shown  by 
the  exalted  opinion  of  his  own  attainments  and  importance,  and 
a  great  laudation  of  members  of  his  family.  He  becomes  boast- 
ful, untruthful,  dishonest,  and  forgetful,  neglecting  engagements, 
business,  self,  and  family.  He  frequently  makes  extravagant 
purchases  and  may  waste  large  sums  of  money  before  his  con- 
dition   of    irresponsibility    is    recognized,    or    may    unwittingly 


7l6  GENERAL   PARALYSIS. 

resort  to  dishonest  means  to  obtain  money.  In  many  instances 
the  patient  develops  ideas  of  an  enterprising  character,  and 
resorts  to  all  forms  of  expedients,  which,  to  his  mind,  are  going 
to  improve  his  or  his  family's  station  and  worldly  condition.  He 
determines  to  change  his  occupation  or  business  or  attempts  to 
instruct  the  authorities  in  what  he  conceives  should  be  their 
duties. 

Moral  lapses  or  paretics  are  most  frequent  during  this  stage, 
consisting  of  acts  of  theft,  drunkenness,  violent  impulses,  or 
indecent  assaults,  in  individuals  who  have  previously  possessed 
a  good  moral  character.  They  become  profane  and  vulgar,  and 
often  resort  to  sexual  excesses.  Associated  with  any  of  the 
above  symptoms  may  be  any  one  or  more  of  the  following  phys- 
ical conditions:  Tremor  of  the  muscles  about  the  mouth,  naso- 
labial folds,  and  of  the  tongue,  causing  a  slight  slur  or  hesitating 
speech;  alterations  in  the  pupils,  or  one  pupil  becoming  some- 
what larger  than  the  other,  or  the  pupils  may  be  contracted  to 
pin-head  size  with  loss  of  accommodation;  attacks  of  vertigo, 
or  epileptiform  or  apoplectiform  seizures.  The  gastric,  intes- 
tinal, hepatic,  and  nephritic  secretions  are  disturbed,  and  there 
may  be  headache  and  insomnia.  After  a  variable  duration, 
continuing  in  a  mild  degree  for  many  months,  the  second  stage 
begins. 

Second  or  maniacal  stage  is  much  the  same  as  a  severe  attack 
of  acute  mania  (megalomania),  plus  the  physical  signs  of  paresis 
and  the  delusions  or  ideas  of  grandeur.  The  patient  is  excess- 
ively restless,  boasting  of  his  great  wealth,  intentions,  prospects, 
and  influence;  one  moment  the  most  important  of  individuals, 
the  next  giving  away  thousands,  and,  if  doubt  is  expressed  as  to 
his  ability  to  do  so,  making  it  millions  and  often  billions;  pre- 
senting houses  and  lands,  titles  and  offices,  with  unstinted 
liberality.  It  is  to  be  noted  that  these  so-called  delusions  of  the 
paretic  are  in  reality  conceptions,  or  an  expansive  delirium,  for 
when  contradicted  the  patient  makes  no  effort  to  defend  them; 
they  seem  to  be  really  assertions  and  reassertions,  continuing 
until  incoherency  restrains  the  airy  imagination.  If  questioned 
as  to  his  health,  he  replies,  enthusiastically,  "First-rate;   never 


GENERAL   PARALYSIS.  717 

better  in  my  life."  The  patient  is  sleepless,  noisy,  and  destruc- 
tive, with  attacks  of  blind,  uncalculating  violence,  resisting  all 
who  attempt  to  restrain  or  molest  him.  The  violent  impulses 
of  paretics  are  similar  to  the  furious  excitement  of  the  post- 
epileptic maniac. 

The  physical  signs  are  more  pronounced:  the  characteristic, 
hesitating,  and  slurring  speech  increases;  the  pupillary  changes 
becoming  more  marked;  the  tremor  of  the  tongue  and  lips 
increasing  and  spreading  to  the  upper  extremities;  the  gait 
ataxic;  the  patellar  reflex  increased,  or,  rarely,  diminished;  the 
sphincter  of  the  bladder  disordered,  and  sometimes  there  occurs 
paralysis  of  the  anal  sphincter. 

During  the  progress  of  the  second  stage  are  developed  cerebral 
crises — syncope,  petit  or  grand  mal,  apoplectiform  attacks,  or 
paralytic  seizures.  Few  cases  but  show  one  or  more  of  these 
conditioiiS.  There  also  occur  myosis  and  loss  of  light  reaction, 
and  increased  wrist  and  elbow  jerks.  The  maniacal  stage  is  of 
shorter  duration  than  any  other,  and  is  usually  succeeded  by 
the — 

Stage  of  dementia,  the  patient  presenting  all  the  evidences  of 
failing  mentality,  with  paralysis,  trophic  changes,  as  shown  by 
the  occurrence  of  bed-sores,  cystitis,  diarrhea,  and  arthropathies, 
or  Charcot's  joints,  the  patient  emaciating  rapidly,  death  closing 
the  scene  within  a  few  months.  Rarely  the  maniacal  stage  is 
preceded  or  replaced  by  a  condition  of  melancholia  with  expan- 
sive hypochondriacal  delusions.  In  a  few  instances  a  genuine 
lucid  interval  has  followed  either  the  prodromal  or  maniacal 
stage. 

The  spinal  form  of  general  paresis  is  fairly  frequent,  in  which 
symptoms  of  spinal  sclerosis  are  added  to  the  mental  ataxic 
phenomena  of  the  usual  form. 

Diagnosis. — The  development  of  the  following  symptoms  re- 
moves all  difficulties  in  diagnosis:  Mental — alteration  in  char- 
acter, loss  of  memory,  defective  will-power,  changed  moral 
sense,  insomnia,  violent  impulses,  melancholia  or  mania,  un- 
systemiatized  delusions  of  expansive  character,  with  an  exalted 
sense  of  well-being,  gradually  ending  in  dementia.     Physical — 


7l8  DEMENTIA. 

hesitating,  slurring  speech;  tremor  of  the  lips,  tongue,  and  upper 
extremities;  pupillary  changes,  myosis,  loss  of  light  reaction; 
exaggerated  wrist-,  elbow-,  and  knee-jerk;  attacks  of  syncope, 
vertigo,  epileptiform  seizures,  ataxia,  trophic  changes,  and 
finally  paralysis. 

Paralytic  insanity,  organic  dementia,  or  dementia  paralytica, 
is  not  the  same  condition  as  general  paralysis.  It  is  the  form  of 
mental  failure  succeeding  to  gross  brain  lesions,  such  as  apo- 
plexy, tumors,  softening,  trauma,  and  sclerosis,  associated  with 
either  hemiplegia  or  paraplegia. 

Prognosis. — Unfavorable.  Remissions  very  rarely  occur. 
The  duration  of  general  paresis  has  been  considerably  length- 
ened by  the  hospital  care  of  such  patients  now  in  vogue  in  all 
properly  conducted  institutions  for  the  insane. 

Treatment. — The  care  of  the  general  health  and  meeting  symp- 
toms as  they  arise  is  all  that  can  be  done  for  general  paresis.  It 
is  claimed  that  if  the  condition  be  recognized  early  in  the  pro- 
dromal stage,  the  stage  of  cerebral  congestion  or  vasomotor 
paresis,  much  good  may  be  accomplished,  and,  if  not  cured,  may 
be  held  in  check  for  a  long  period  of  time  by  the  use  of  such 
drugs  as  digitalis  or  ergot. 

The  maniacal  excitement  may  be  quieted  by  the  use  of  the 
hot  bath,  isolation  (not  seclusion),  and  the  administration  of 
small  doses  of  hyoscin  hydrobromid,  which  seems  to  exert  an 
alterative  action  on  the  brain.  For  the  insomnia,  trional,  gr. 
XX  to  XXX  (1.3  to  2  gm.),  repeated,  is  usually  satisfactory. 

If  a  reliable  syphilitic  history  is  obtained,  a  thorough  course 
of  mercury  and  iodids  should  be  administered.  All  means  that 
promote  the  constructive  metamorphosis  are  indicated  in  this 
most  characteristic,  progressive  malady. 

DEMENTIA. 

Synonym. — Acquired  feeble-mindedness. 

Definition. — A  progressive  general  weakening  of  the  mind, 
characterized  by  a  loss  of  reasoning  capacity,  a  diminution  of 
feeling,  a  weakened  volitional  and  inhibitory  power,  and  failure 


DEMENTIA. 


719 


of  memory,  associated  with  lack  of  the  power  of  attention,  in- 
terest, and  curiosity,  in  varying  degrees,  in  an  individual  pre- 
viously possessed  of  these  mental  qualities. 

Form.s. — Acute  dementia;  alcoholic  dementia;  dementia  apoplec- 
tica  or  paralytica;  dementia  choreica;  chronic  or  secondary  de- 
mentia; dementia  epileptica;  organic  dementia;  partial  dementia; 
primary  dementia;  dementia  senilis;  dem^entia  syphilitica;  de- 
mentia toxica. 

Causes. — Deficient  or  feeble  mental  inheritance;  age;  athe- 
roma; mania,  melancholia,  paranoia,  and  other  forms  of  insan- 
ity; organic  brain  conditions;  alcoholism;  syphilis;  develop- 
mental changes;  climacteric. 

Pathology. — In  acute  dernentia  the  changes  are  dynamic.  In 
priynary  dementia  there  is  probably  atrophy  of  certain  «ells 
from  over-stimulation,  the  tissues  being  normally  deficient. 
In  secondary  dementia  the  chief  changes  are:  "alteration  in 
the  size  of  the  vessels,  owing  to  the  thickening  and  disten- 
tion, the  thickening  being  most  marked  in  the  deep  layers,  and 
in  the  walls  of  the  vessels  are  fatty  granules  and  hematoidin. 
The  perivascular  canals  are  enlarged.  The  changes  in  the  cells 
may  be  described  as  deficiency  in  the  number  of  pyramidal 
cells,  and  a  want  of  distinctness  of  outline  and  branches, 
the  nuclei  being  larger,  but  changed  in  form,  and  only  capable 
of  slight  carmine  staining,"  In  senile  dementia  there  is  gen- 
eral  atrophy   and  degeneration  of  all  the  tissues  of  the  brain. 

Symptoms. — The  onset,  extent,  and  variety  of  the  impaired 
mentality  differ  greatly.  In  some  patients  the  evidences  of  the 
failing  mind  are  seen  with  the  subsidence  of  the  mania,  melan- 
cholia, or  other  insanity,  or  soon  after  the  development  of  the 
particular  cause,  while  in  another  group  of  cases  the  develop- 
ment is  slow  and  insidious.  The  difference  in  the  intensity  is 
marked;  in  one  case  the  changes  being  scarcely  noticeable,  the 
patient  being  simply  less  active  than  before,  showing  a  slight 
indifference  to  his  environment;  while  in  others  the  patients 
remain  for  hours  alone,  making  no  effort  at  movement  and  with 
little  or  no  expression  of  the  face;  while  still  another  class  of 
cases   is  oblivious   to   the   demands  for  food  or  drink,   or  the 


720  DEMENTIA. 

calls  of  nature,  existing  "in  the  darkness  of  perpetual  intellectual 
and  moral  night."  Between  these  symptoms  are  all  varieties 
and  degrees  of  mental  enfeeblement,  the  physical  symptoms  of 
dementia  varying  with  the  particular  cases,  many  enjoying  the 
best  or  health,  eating  and  sleeping  well ;  while  others  are  always 
unwell,  first  one  organ  and  then  another  being  affected;  still 
another  group  suffers  from  chronic  diarrhea,  which  finally  causes 
death.  Dementia  patients  seem  predisposed  to  tuberculosis, 
nephritis,  and  epilepsy. 

Acute  dementia,  or  "stupor  with  dementia,"  is  to  be  distin- 
guished from  "stupor  with  melancholia."  The  onset  is  rather 
sudden,  with  or  without  mania  or  melancholia,  after  some 
brain  or  bodily  exhaustion,  shock,  or  fright ;  the  patient,  a  young 
person,  "is  horror-stricken,  paralyzed  in  mind,  not  merely  de- 
ranged, not  depressed  or  excited,  but  deprived  of  feeling  and 
intellect;  his  movements,  if  there  be  any,  are  automatic,  but 
frequently  he  is  motionless,  standing  or  sitting,  staring  at  va- 
cancy for  hours  and  days"  (Blandford).  These  patients  will  not 
converse,  and  do  not  reply  to  questions,  or  but  slowly,  and  in 
monosyllables,  and  their  faces  have  a  blank  expression. 

Alcoholic  dementia,  the  mental  weakness  resulting  from  excess- 
ive use  of  alcohol.  Inebriety  is  a  form  of  dementia,  there  exist- 
ing an  uncontrollable  alcoholic  habit,  with  weakened  or  absent 
will-power  and  impaired  mentality.  Sutherland  defines  seven 
forms  of  insanity  from  alcoholic  excess:  (i)  Intoxication;  (2) 
delirium  tremens;  (3)  mania-a-potu;  (4)  dipsomania;  (5)  mania 
of  suspicion;  (6)  chronic  alcoholism  or  dementia;  (7)  general 
paralysis. 

Denientia  apoplectica  or  paralytica  is  an  organic,  or  terminal 
dementia  due  to  the  cerebral  changes  sometimes  following  a 
severe  apoplectic  seizure,  and  is  usually  associated  with  hemi- 
plegia. 

Dementia  choreica  is  a  feeble-mindedness  associated  with 
chronic  or  hereditary  chorea,  or,  in  some  cases,  probably  the 
result  of  chorea. 

Chronic  dementia  is  the  designation  applied  to  all  forms  of  de- 
mentia that  have  existed  for  one  or  more  years. 


DEMENTIA.  721 

Dementia  epileptica  is  the  slow  mental  impairment  resulting 
from  long-continued  and  frequently  occurring  epileptic  con- 
vulsions. 

Organic  dementia,  the  mental  deterioration  resulting  from 
gross  organic  brain  lesions,  such  as  sclerosis,  tumor,  embolism, 
or  trauma. 

Partial  dem^entia  is  an  incomplete  form  of  dementia  in  which 
the  mental  enfeeblement  is  associated  with  such  a  degree  of 
intelligence  and  memory  that  the  qualifying  term  "partial"  is 
applicable.  This  variety  of  dementia  constitutes  the  majority 
of  able-bodied,  working,  chronic  insane  patients  seen  in  insane 
hospitals. 

Primary  dementia  is  seen  most  frequently  in  the  young,  devel- 
oping slowly  and  insidiously,  without  any  symptoms  of  mania 
or  melancholia,  usually  in  a  youth  who  has  given  promise  of  a 
bright  future,  by  a  slowly  progressive  indifference  to  his  former 
occupation,  studies,  or  surroundings,  with  developing  careless- 
ness and  negligence  of  person  and  proprieties,  no  amount  of 
external  stimulus  serving  to  rouse  the  receding  mentality,  until 
finally  the  downward  course  ends  in  dementia  so  decided  that, 
but  for  the  history  of  the  individual,  the  case  would  be  classed  as 
congenital,  or  imbecility. 

Secondary,  sequential  or  chronic  dementia,  is  the  most  common 
variety  of  mental  impairment  following  mania,  melancholia, 
and  other  insanities.  According  to  Bevan  Lewis,  20  per  cent, 
of  manias  and  15  per  cent,  of  melancholias  become  permanent 
dementia. 

Dementia  senilis  is  the  result  of  cerebral  atrophy,  with  its  con- 
sequent failing  mental  power.  Loss  of  memory  for  recent 
events  is  one  of  the  most  common  symptoms.  The  disease  often 
begins  as  a  senile  mania,  melancholia,  or  delusional  insanity. 

Dementia  syphilitica  is  the  feeble-mindedness  resulting  from 
cerebral  syphilis.  This  group  of  patients  is  always  sanguine, 
and  assert  they  are  "  all  right,"  "  never  sick  in  my  life,"  and  yet 
una,ble  to  assist  or  care  for  themselves.  This  form  of  dementia 
has  many  symptoms  akin  to  general  paresis,  and,  indeed,  is  often 
termed  "pseudo-paresis." 
46 


722  DISEASES    OP    THE    SKIN. 

Dementia  toxica  is  the  mental  failure  produced  by  the  long- 
continued  and  excessive  use  of  opium,  cocain,  and  chloral. 
Chronic  plumbism  is  also  given  as  a  cause. 

Diagnosis.— Acute  dementia  is  often  misnamed  melancholia 
with  stupor,  but  if  the  patient  is  in  the  teens  the  probabilities  are 
that  it  is  a  case  of  the  former,  while  if  past  forty  it  is  almost 
certainly  the  latter. 

The  distinction  between  dementia  and  idiocy  or  imbecility 
must  always  be  determined.  Esquirol's  graphic  description  is 
well  worth  remembering:  "The  dement  was  a  rich  man  who 
has  become  poor;  the  idiot,  on  the  contrary,  has  always  been  in 
a  state  of  want  and  misery." 

Prognosis. — Acute  dementia  is  generally  favorable.  All 
other  varieties  are  incurable.  The  average  life-time  of  dements 
is  placed  at  about  twelve  years,  the  great  majority  dying  of 
tuberculosis,  nephritis,  or  apoplexy. 

Treatment. — Patients  suffering  from  acute  dementia  should 
be  placed  on  the  Mitchell  rest  regime,  with  attention  to  all  the 
secretions.  If  Dr.  Mitchell's  directions  are  carefully  followed 
the  great  majority  of  cases  of  acute  dementia  will  recover 
within  nine  to  twelve  months. 

For  the  other  forms  of  dementia,  unfortunately,  there  is  no 
cure,  the  treatment  resolving  itself  into  attention  to  the  general 
health,  with  proper  custodial  oversight. 

DISEASES  OF  THE  SKIN. 

General  Symptomatology. — -To  acquire  even  the  most  slight 
knowledge  of  diseases  of  the  skin,  a  definite  understanding  of  the 
individual  lesions  or  objective  phenomena  must  be  obtained,  as 
it  is  the  aggregation  of  these  lesions  that  constitutes  the  exter- 
nal manifestations  of  these  affections  and  the  basis  of  diagnosis. 
Some  lesions  are  initial  manifestations  and  are  termed  primary 
lesions;  others  result  from  various  modifications  of  the  original 
lesions  and  are  termed  secondary  lesions. 

The  prim,ary  lesions  are  macules,  papules,  vesicles,  blebs,  pus- 
tules, tubercles,  wheals,   and  tumors.     These  represent  definite 


DISEASES    OF    THE    SKIN. 


723 


structural  changes  in  the  skin.  The  definitions  of  these  terms  by- 
various  dermatologists  must  therefore  be  very  similar. 

Macules  are  variously  sized  and  shaped  discolored  areas  of  the 
skin  characterized  by  the  absence  of  elevation  or  depression. 

Papules  are  circumscribed  solid  areas  of  elevations  of  the  skin, 
the  size  of  which  varies  from  that  of  a  pin-head  to  a  pea. 


Macule 


Papule 


Tubercle 


Vesicle 


Pustule 


Tumor 


A 


Crust 


Scale 


Excoria- 
tion 


Fissure 


XXX 


Cicatrix 


Primary. 


Secondary. 


Fig.  60. — Lesions  of  the  Skin. 

Vesicles  are  circumscribed  elevated  areas  of  the  skin  contain- 
ing clear  or  opaque  fluid,  varying  in  size  from  a  pin-head  to  a 
pea. 

Blebs  or  hullcB  are  round  or  irregularly  shaped  epidermal  ele- 
vations containing  clear  or  opaque  fluid  and  varying  in  size  from 
a  pea  to  a  goose-egg. 

Pustules  are  circumscribed  epidermal  elevations  containing 
pus,  and  varying  in  size  from  a  pin-point  to  a  finger-nail. 

WPieals  or  pomphi  are  circumscribed  edematous  elevations  of 
the  skin  of  a  fugitive  or  ephemeral  character. 


724  ANEMIA   OF    THE   SKIN. 

Tubercles  are  circumscribed,  solid,  pea-sized  elevations,  situ- 
ated deeply  in  the  skin. 

Tumors  are  variously  sized,  shaped,  and  constituted  prom- 
inences the  seat  of  which  is  in  the  deep  layers  of  the  integument. 

The  secondary  lesions  include  scales,  crusts,  excoriations,  fis- 
sures, ulcers,  scars,  stains,  and  any  other  secondary  structural 
change.  These  manifestations  do  not  bear  directly  on  the  diag- 
nosis and  their  detailed  description  may  therefore  be  omitted. 

Subjective  symptoms  in  dermatologic  affections  are  itching, 
burning,  tingling,  smarting,  pain,  and  sense  of  heat.  The  in- 
tensity of  these  manifestations  is  necessarily  subject  to  great 
variation.  They  may  exist  separately  or  in  different  degrees  of 
combination. 

•   ANEMIA  OF  THE  SKIN. 

Anemia  of  the  skin  consists  in  a  diminution  in  the  quantity 
or  alteration  in  quality  of  its  blood  supply  and  may  be  general  or 
local,  transient  or  persistent.  Generalized  dermal  anemia  occurs 
as  a  part  of  a  general  anemia  from  various  causes,  and  as  a  result 
of  cerebral  anemia.  Localized  anemia  follows  the  application 
of  cold,  pernio,  frost-bite,  Raynaud's  disease,  emboli  and  thrombi, 
keloid,  morphea,  scleroderma,  alopecia  areata,  cicatrices,  etc. 
Transient  anemia  occurs  as  the  result  of  shock,  syncope,  anger, 
fear,  hemorrhages,  etc.  Persistent  anemia  is  that  which  occurs 
as  the  result  of  some  structural  change  in  the  skin  such  as  mor- 
phea and  alopecia  areata;  it  also  accompanies  persistent  general 
anemias. 

HYPEREMIA  OF  THE  SKIN. 

Hyperemia  or  congestion  of  the  skin  consists  in  an  increase 
of  its  blood  supply  due  to  overfilling  of  the  blood-vessels  without 
other  structural  change.  As  in  other  parts  of  the  body,  it  may 
be  active  or  passive,  idiopathic  or  symptomatic.  The  most 
important  hyperemias  are  erythema  simplex  and  erythema 
intertrigo. 


.  ERYTHEMA   MULTIFORME.  7^5 

Erythema  simplex  is  a  circulatory  disturbance  of  the  integu- 
ment characterized  by  variously  sized  and  shaped  areas  of  red- 
ness unattended  by  elevation  or  depression.  It  is  accompanied 
by  mild  itching  or  burning,  and  disappears  on  pressure.  It  may 
be  due  to  exposure  to  extremes  of  temperature  {erythema  calor- 
tcum),  exposure  to  the  sun's  rays  {erythema  solare),  injury 
{erythema  traumaticum) ,  irritation  of  poisonous  plants  {erythema 
venenatum),  or  to  the  absorption  of  drugs,  antitoxins,  ptomains, 
etc.,  {toxic  erythema). 

The  treatment  should  be  internal  and  external.  As  many  of 
these  cases  are  due  to  intestinal  autointoxication,  fractional  doses 
of  calomel  followed  by  a  saline  purgative  should  be  administered 
routinely,  except  in  those  instances  in  which  the  affection  is 
obviously  due  to  external  causes.  Externally,  dusting  powders 
such  as  zinc  oxid  and  starch,  and  sedative  lotions  such  as  satu- 
rated boric-acid  solution  are  very  beneficial. 

Erythema  intertrigo  or  chafing  is  the  variety  of  hyperemia  en- 
countered in  regions  such  as  the  buttocks,  genital  regions,  and 
flexures  of  joints,  in  which  the  skin  surfaces  are  in  apposition 
and  rub  one  on  the  other.  In  the  obese  and  in  infants  it  is  very 
frequent  and  often  develops  into  a  true  dermal  inflammation. 

Redness,  heat,  and  burning  are  symptoms;  and  sometimes 
there  may  be  a  mucoid  discharge.  Cleanliness  and  the  local 
application  of  dusting  powders  such  as  magnesium  carbonate, 
zinc  oxid,  subnitrate  of  bismuth,  talc,  etc.,  serve  to  prevent 
and  relieve  the  condition. 

INFLAMMATIONS  OF  THE  SKIN. 

ERYTHEMA  MULTIFORME. 

Erythema  multiforme  is  an  inflammatory  disease  of  the  skm 
characterized  by  symmetric,  bright  or  dark  reddish,  more  or  less 
variegated  macules,  papules,  and  vesicles,  occurring  discretely 
or  in  patches,  often  sharply  defined,  and  marginate,  of  various 
size  and  shape,  running  an  acute  course  (Duhring).  Constitu- 
tional disturbance  usually  precedes  or  accompanies  it,  and,  is 


726  ERYTHEMA   SCARLATINOIDES. 

manifested  by  feverishness,  malaise,  rheumatoid  pains,  anorexia, 
etc.  This  is  followed  by  the  sudden  appearance  of  the  eruption 
which  may  consist  of  macules,  papules,  vesicles,  or  blebs,  the 
eruption  being  designated  by  the  predominant  type  of  lesions. 
It  is  bright  or  dusky  red  in  color  at  first,  but  soon  becomes 
purplish  or  bluish  and  shows  a  great  predilection  for  extensor 
surfaces  such  as  the  backs  of  hands  and  dorsal  surfaces  of  the  feet. 
Other  portions  of  the  body,  however,  are  not  exempt.  The 
subjective  symptoms  are  itching  and  burning. 

The  direct  cause  of  the  affection  is  undetermined  but  early 
adult  life,  spring  and  autumn  seasons,  changes  in  the  weather, 
and  the  rheumatic  diathesis  are  known  to  influence  its  pro- 
duction materially.  The  pathologic  changes  consist  in  dilata- 
tion of  the  dermal  vessels  with  moderate  serous  and  cellular 
exudation  into  the  tissues.  In  distinguishing  the  condition 
from  other  cutaneous  affections  it  should  be  remembered  that 
the  eruption  appears  suddenly  in  crops  lasting  from  one  to 
four  weeks,  is  multiform  in  character,  is  most  marked  on  exten- 
sor surfaces,  has  a  purplish  red  or  violaceous  color,  is  accompa- 
nied by  constitutional  symptoms,  and  undergoes  spontaneous 
involution  often  reappearing  when  the  necessary  contributory 
conditions  (such  as  change  in  the  weather)  are  supplied. 

Treatment. — In  all  cases,  the  administration  of  fractional 
doses  of  calomel  followed  by  a  saline  is  of  benefit.  Quinin  and 
the  salicylates  often  serve  to  hasten  the  eruption's  involution 
and  to  relieve  the  constitutional  manifestations.  Locally, 
antipruritic  lotions  are  of  value.     The  following  may  be  used: 

I^.      Acid  carbol 5ii  8 .  c.c. 

Glycerin 5ii  8 .  c.c. 

Aquas Oi  480 ,  c.c. 

M.  S. — Poison,  apply  locally  twice  daily. 

ERYTHEMA     SCARLATINOIDES. 

Erythema  scarlatinoides  is  a  variety  of  exudative  erythema 
resembling  scarlet  fever  in  its  cutaneous  manifestations  but 
differing  from  it  in  its  other  characteristics.  The  eruption  ap- 
pears suddenly  with  very  slight  constitutional  reaction,  is  punc- 


ERYTHEMA   NODOSUM.  727 

tiform  or  diffuse,  and  disappears  by  desquamation  in  from  one 
to  six  days.  The  face  is  seldom  attacked;  the  strawberry  tongue 
is  absent;  recurrence  is  common;  and  the  affection  is  non- 
contagious. It  may  arise  as  an  idiopathic  condition  or  it  may 
accompany  septicemia,  pyemia,  ptomain  poisoning,  rheumatism, 
uremia,  and  the  infectious  fevers.  A  similar  eruption  may 
follow  the  absorption  of  quinin,  salicylates,  copaiba,  belladonna, 
and  similar  drugs.  The  affection  is  devoid  of  danger  and  ter- 
minates favorably  usually  within  a  week. 

Treatment. — When  the  cause  can  be  ascertained,  it  should  be 
promptly  removed  in  order  to  prevent  persistence  or  recurrence 
of  the  condition.  Usually  no  local  treatment  is  required. 
Dusting  powders  or  sedative  lotions  may  be  necessary  if  there 
is  any  attendant  itching. 

ERYTHEMA  NODOSUM. 

Erythema  nodosum  is  an  inflammatory  disease  attended  by 
the  formation  of  symmetric,  round  or  oval,  node-like  swellings 
and  accompanied  by  more  or  less  constitutional  disturbance. 
The  onset  is  marked  by  slight  fever,  rheumatoid  pains,  and  loss 
of  appetite.  These  are  shortly  followed  by  the  appearance  of 
tense,  rosy,  red  nodes  or  swellings,  usually  over  both  tibi«, 
resembling  erysipelas.  They  are  at  first  hard  and  extremely 
tender  to  the  touch  but  later  soften  and  their  color  becomes 
that  of  a  bruise.  Suppuration  never  occurs  and  the  lesions 
undergo  spontaneous  involution  in  from  a  week  to  ten  days. 
The  affection  is  usually  observed  in  children  and  young  adults 
particularly  in  the  spring  and  fall.  It  is  often  associated 
with  rheumatism  and  gastrointestinal  disorders.  The  structural 
changes  incident  to  this  disease  are  congestion,  serous  and 
cellular  infiltration,  and  hemorrhages.  It  is  closely  related  to 
erythema  multiforme. 

Treatm.ent. — Rest,  with  elevation  of  the  affected  parts  is  essen- 
tial. The  application  of  lead-water  and  laudanum  serves  to  re- 
lieve the  pain.  On  no  account  should  the  lesion  be  incised. 
Internally,  fractional  doses  of    calomel    followed    by    a    saline 


728  ERYTHEMA   INDURATUM. 

should   be   given   to   relieve   the   gastrointestinal  tract   of  any 

offending  material  and  to  promote  elimination.  Quinin,  salol, 

salicin,   sodium  salicylate,   and  phenacetin  may  be  employed 
with  benefit. 

ERYTHEMA  INDURATUM. 

Erythema  induratum  is  an  uncommon  inflammatory  affec- 
tion observed  in  scrofulous  individuals,  particularly  strumous 
girls,  characterized  by  the  formation  of  circumscribed  infiltrated 
areas,  usually  in  the  calves  of  the  legs,  which  terminate  either 
in  absorption  or  necrosis  with  the  formation  of  an  indolent  ulcer. 
Overwork  and  prolonged  standing  seem  to  be  etiological  factors. 
It  occurs  usually  in  winter  in  poorly  nourished  individuals  with 
feeble  circulation,  and  is  extremely  chronic  with  a  tendency  to 
recurrence. 

Treatment. — In  all  cases  it  is  extremely  necessary  first  to  im- 
prove the  patient's  general  condition  by  good  food,  fresh  air,  sun- 
shine, cod-liver  oil,  syrup  of  the  iodid  of  iron,  and  similar  meas- 
ures. Locally,  elevation  of  the  parts  is  of  decided  advantage 
and  in  event  of  ulceration,  surgical  cleanliness  is  all  that  is 
necessary. 

URTICARIA. 

Synonyms. — Hives ;  nettle-rash. 

Definition. — An  inflammation  of  the  skin  characterized  by  the 
development  of  wheals  of  a  whitish,  pinkish,  or  reddish  color, 
accompanied  by  stinging,  pricking,  and  tingling  sensations, 
often  associated  with  febrile  and  gastric  symptoms. 

Causes. — It  is  usually  due  to  some  indiscretion  in  diet.  Cer- 
tain substances  such  as  fish,  crabs,  lobsters,  cheese,  sausage, 
buckwheat,  strawberries,  nuts,  pork,  etc.,  in  susceptible  individ- 
uals bring  about  an  attack.  Antitoxin  serums,  copaiba, 
quinin,  cubebs,  chloral,  salicylic  acid,  morphin,  etc.,  may  also 
give  rise  to  the  condition.  Intestinal  parasites  and  undigested 
food  are  also  causes.     Locally,  the  bites  or  stings  of  insects, 


URTICARIA.  729 

exposure  to  heat,  the  sting  of  the  nettle,  and  traumatism  such 
as  caused  by  the  stroke  of  a  whip-lash,  often  produce  the  condi- 
tion. Less  frequent  causes  include  reflex  irritation  from  hepatic, 
renal,  uterine,  or  bladder  derangements,  puncture  of  pleural 
effusion,  rupture  of  an  hydatid  cyst,  malaria,  emotion, 
neurotic  conditions,  purpura,  pregnancy,  lactation,  and  the 
menopause. 

Pathology. — An  acute  edematous  condition  of  the  papillary 
layer  of  the  skin,  characterized  by  the  rapid  development  of  a 
"wheal" — a  more  or  less  firm  elevation — consisting  of  a  cir- 
cumscribed collection  of  the  semifluid  material,  the  result  of  a 
rapid  exudation  into  the  upper  layers  of  the  skin.  The  produc- 
tion of  the  wheal  is  the  immediate  result  of  the  disturbance  of 
the  vasomotor  system,  which  is  shown  by  the  interference  of 
the  circulation  in  the  wheal,  the  blood  being  driven  from  its 
center  to  its  periphery,  causing  the  whitish  apex  and  red  areola 
so  characteristic  of  the  developed  "hive." 

Symptoms. — An  attack  of  "  hives"  is  characterized  by  the  sud- 
den development  of  wheals  upon  the  cutaneous  surface,  which  usu- 
ually  as  suddenly  disappear,  their  site  being  temporarily  marked 
by  a  spot  of  redness  or  hyperemia.  With  the  appearance  of  the 
wheal  occur  distressing  itching,  burning,  tingling,  crawling, 
pricking,  and  stinging  sensations,  to  relieve  which  the  patient 
still  further  irritates,  tears,  or  otherwise  wounds  the  surface  by 
scratching,  whence  are  often  developed  deep-colored,  fiat,  lentic- 
ular papules. 

Very  frequently  an  attack  of  "  hives"  is  associated  with  fever, 
tfeadache,  and  gastric  disorder.  The  wheals  may  appear  upon 
any  portion  of  the  body;  their  size  varies  from  that  of  a  pea  to 
that  of  a  walnut  or  an  egg — "giant  wheals";  the  number  vary- 
ing, sometimes  being  so  numerous  as  to  cover  the  whole  sur- 
face. The  shape,  size,  color,  and  number  of  the  wheals  that  may 
occur  have  given  rise  to  a  number  of  names  to  designate  the 
lesions.  Thus,  urticaria  annularis  occurs  in  rings;  urticaria 
figurata  occurs  in  spirals;  urticaria  vesiculosa  has  a  vesicular 
development  on  the  summit  of  the  wheal;  urticaria  bullosa,  a 
bullous    development   at   the    summit;    urticaria   papulosa,    or 


730  URTICARIA. 

lichen  urticatus,  the  wheal  and  a  small  papule  are  combined; 
urticaria  tuberosa,  or  giant  wheals;  urticaria  hcBmorrhagica,  or 
urticaria  purpurata,  a  combination  of  urticaria  and  purpura ; 
urticaria  evanida,  a  rapid  appearance  and  disappearance  of 
the  lesion;  urticaria  perstans,  slow  disappearance;  urticaria 
conferta,  when  the  wheals  are  confluent;  urticaria  pigmentosa, 
when  the  wheals  are  succeeded  by  pigmentations  of  the  site,  the 
tints  varying  from  dark  brown,  greenish  yellow,  to  a  chocolate 
color;  urticaria  febrilis,  when  the  wheals  are  associated  with 
fever;  urticaria  ah  ingestis,  when  associated  with  indigestion, 
urticaria  factitia,  when  the  wheals  are  produced  artificially. 

Prognosis. — Acute  attacks  respond  quickly  to  treatment,  but 
recurrences  are  common. 

Treatment. — In  the  early  stage,  an  emetic  will  be  of  value 
but  usually  the  condition  is  well  advanced  when  seen  by  the 
physician,  necessitating  the  administration  of  a  brisk  purgative. 
Following  this  some  intestinal  antiseptic  such  as  salol,  or  sodium 
salicylate  should  be  given.  The  diet  should  be  as  plain  as 
possible,  care  being  taken  to  eliminate  those  substances  for 
which  the  patient  has  an  idiosyncrasy.  Among  other  drugs 
of  value  in  this  condition  may  be  mentioned  quinin,  phenacetin, 
antipyrin,  pilocarpin,  atropin,  tincture  of  belladonna,  ammo- 
nium chlorid,  arsenic,  and  potassium  bromid.  The  following  pill 
is  useful  in  many  cases: 

I^.     Pulv.  pilocarpi, 

Ext.    guaiaci aa  gr.  jss  aa  o  .  i  gm. 

Lithii  benzoat gi"-  iij  o  •  2  gm. 

M.  S. — Two  to  4  each  twenty-four  hours. 

If  there  be  atonic  dyspepsia  and  constipation,  the  following 
combination  is  beneficial: 

I^.      Magnesii  sulphat Bj  32.  gm. 

Ferri  sulphat gr.  xvj  i .  gm. 

Sodii  chloridi 5ss  2  .  gm. 

Acidi  sulphurici  dil f  5ij  8  .  c.c. 

Infus.  cascarillae f  Siv  120.  c.c. 

M.  S. — Tablespoonful  before  breakfast,  diluted. 


URTICARIA.  731 

When  emesis  fails  to  relieve  the  condition,  or  is  contrain- 
dicated,  antispasmodics  and  vasodilators  may  be  tried.  Atro- 
pin  in  large  doses  (gr.  4/150  hypodermatically)  or  nitroglyc- 
erin (gr.  i/ioo  hypodermatically)  is  probably  the  most 
useful  for  this  purpose.  Amyl  nitrite,  by  inhalation,  is  espe- 
cially valuable  in  those  cases  where  there  is  much  edema  about 
the  face  and  neck.  It  is  peculiar  in  its  action,  relieving  the 
spasms  only  in  the  head,  neck,  and  upper  part  of  the  chest, 
and  should  prove  extremely  useful  in  those  distressing  cases 
where  there  is  an  edema  of  the  tongue,  pharynx,  or  glottis. 
In  this  condition  a  most  useful  adjunct  to  treatment  is  a  spray 
of  adrenalin  chlorid. 

Dr.  E.  B.  Finch  of  New  York  has  been  very  successful  in  the 
treatment  of  urticaria  by  the  use  of  creosote.  He  says:  "In 
acute  toxic  cases,  if  they  be  seen  early,  before  the  eruption  is 
fully  developed,  the  administration  of  creosote  may  greatly 
modify  or  even  abort  an  attack.  Four  minims  in  elastic  cap- 
sules with  2  minims  in  enteric  pill  should  be  given  for  an  initial 
dose,  followed  every  fifteen  or  twenty  minutes  with  2  minims 
in  capsule  until  an  effect  is  produced.  In  the  recurrent  or 
chronic  forms  of  urticaria  creosote  may  lessen  the  frequency  of 
the  attacks  or  cause  them  to  cease  entirely.  After  each  meal 
and  before  retiring  from  2  to  6  minims  in  elastic  capsule  and  the 
same  amount  in  enteric  pill  should  be  given." 

Locally,  baths,  lotions,  or  dusting  powders  will  be  necessary 
to  relieve  the  itching.  Among  the  most  serviceable  measures 
are:  sponging  with  alcohol,  brandy,  whiskey,  carbolized  water, 
or  witch  hazel,  alkaline  baths,  and  acid  bath.  Duhring  rec- 
ommends the  following: 

I^.     Acidi  carbolici 3iss  6 .  gm. 

Glycerini f  5ij  8  .  c.c. 

Alcoholis f  §viij  240.  c.c. 

Aq.  amygdal.  amar f  oviij  240.  c.c. 

M.  S. — Use  as  a  lotion  two  or  three  times  daily. 


732  ANGIONEUROTIC   EDEMA. 

Bulkley    suggests    the    following: 
I^.     Chloralis, 

Camphorae aa    oj  aa  4  .  gm. 

Misce,  and  incorporate 

with  pulveris  amyli. . .  Sj  to  ij  32  .  to  63  .  gm. 
M.  Keep  tightly  corked  in  a  wide-mouthed  bottle. 
S. — Rub  in  with  hand. 

A  serviceable  formula  is  the  following: 

I^.     Chloroformi f  5  j  4  .  c.c. 

Ung.  zinci  oxid §ij  63  .  gm. 

M.  S. — Apply  locally. 
Or— 

I^.     Menthol gr.  v  0.32  gm. 

Petrolat  ' §i  32 .       gm. 

M.  S. — Apply  locally. 
Or— 

I^,     Acid  benzoic gr.  x  0.6  gm. 

Alcohol f  5i  30.     c.c. 

M.  S. — Apply  locally. 

Urticaria  pigmentosa  begins  in  the  early  months  of  infancy 
and  is  characterized  by  buff -colored  wheals,  with  or  without 
itching,  that  persist  for  a  long  period  and  after  disappearing 
leave  behind  brownish  stains.  It  is  very  rare.  It  is  essen- 
tially chronic  but  seldom  lasts  until  puberty.  The  treatment 
consists  of  internal  and  local  medication  based  on  the  same 
principles  employed  in  other  varieties  of  urticaria. 

ANGIONEUROTIC  EDEMA. 

Angioneurotic  edema  is  a  neurotic  condition  in  which  transient 
circumscribed,  edematous  swellings  appear  on  the  skin,  and 
sometimes  on  the  mucous  membranes,  and  disappear  after  a 
variable  period  without  leaving  behind  any  structural  altera- 
tions. It  arises  usually  without  obvious  cause  and  is  in  all 
probability  a  vasomotor  neurosis.  Certain  drugs  in  susceptible 
individuals  may  induce  it.  Recurrences  are  frequent,  and  when 
the  larynx  is  involved  the  affection  assumes  a  grave  aspect. 
The  treatment  is  similar  to  that  of  urticaria. 


ECZEMA.  733 

ECZEMA. 

Synonyms. — Tetter;  salt  rheum;  scall. 

Definition. — A  non-contagious  inflammation  of  the  skin, 
characterized  by  any  or  all  of  the  results  of  inflammation,  at 
once  or  in  succession,  such  as  erythema,  papules,  vesicles  or 
pustules,  accompanied  by  more  or  less  infiltration  and  itching, 
terminating  in  a  serous  discharge,  with  the  formation  of 
crusts,  or  in  desquamation. 

Forms. — Acute;  subacute;  chronic. 

Varieties. — Eczema  erythematosum ;  eczema  papulosum;  eczema 
vesiculosum;  eczema  pustulosum ;  eczem,a  ruhrum,;  eczem,a  squa- 
mosum; eczema  fissum;  eczem,a  verrucosum-;  eczema  sclerosum. 

Causes. — Eczema  attacks  persons  in  all  spheres — the  rich,  the 
poor,  the  infant  or  the  aged,  and  males  or  females.  Many  fam- 
ilies, especially  those  having  the  "  catarrhal  predisposition  or 
peculiarity  of  constitution,"  seem  more  liable;  indeed,  it  appears 
probable  that  a  predisposition  to  eczema  may  be  transmitted 
from  parent  to  child.  Other  causes  are:  improper  food,  gastro- 
intestinal disorders,  imperfect  elimination  of  products  of  waste, 
intestinal  parasites,  dentition,  deficient  urinary  secretion, 
Bright's  disease,  diabetes,  functional  and  organic  nerve  affec- 
tions, the  rheumatic  and  gouty  diatheses,  vaccination,  prolonged 
contact  of  hot  fomentations,  contact  with  the  poison  vine  (rhus 
toxicodendron)  and  poison  tree  (rhus  venenata),  heat  and  cold, 
and  various  chemic  and  mechanic  irritants. 

Pathology. — Eczema  is  a  catarrhal  inflammation  of  the  skin — 
a  dermatitis,  with  superficial  serous  exudation.  There  is  first 
hyperemia,  or  congestion  of  the  vessels  of  the  skin.  The  hyper- 
emia is  soon  followed  by  a  serous  exudation.  If  the  superficial 
exudation  be  profuse  enough  to  form  small  drops,  and  if  the  epi- 
dermis possess  sufficient  resisting  power  not  to  give  way  immedi- 
ately before  it,  vesicles  form,  producing  the  variety  known  as 
eczema  vesiculosum;  if  the  vesicles  contain  a  large  admixture 
of  young  cells,  so  that  the  serum  be  turbid,  yellow,  and  purulent, 
the  vesicles  become  pustules,  termed  eczema  pustulosum;  if  the 
serous  exudation  be  not  sufficient  to  either  elevate  or  break 
through   the   epidermis,    instead   of   either  vesicles  or  pustules 


734  ECZEMA. 

forming,  there  occur  dry  scales,  rising  from  the  reddened  skin — 
eczema  squamosum.  When  the  exudation  is  sufficient  to 
detach  the  epidermis,  thus  exposing  the  red  and  moist  corium, 
it  is  termed  eczema  rubrum. 

In  chronic  eczema,  the  skin  is  subacutely  inflamed  and  is  very 
much  thickened,  hardened,  and  infiltrated  with  cells  which 
extend  throughout  the  entire  corium,  even  into  the  subacuta- 
neous  connective  tissue.  The  papillse  are  enlarged  and  at  times 
may  be  distinguished  with  the  naked  eye.  Pigmentation  may 
take  place  in  the  deep  layers  of  the  rete  and  in  the  corium,  espe- 
cially about  the  vessels. 

Symptoms. — Eczema  is  the  most  common  of  all  cutaneous 
affections,  with  symptoms  varying  in  accordance  with  the 
particular  variety  of  the  affection  and  the  location,  although  the 
general  characteristics  of  a  catarrhal  inflammation  are  present 
in  all;  these  are  redness,  either  limited  or  diffused;  heat,  of  the 
part  affected;  swelling,  the  result  of  the  serous  exudation,  giving 
rise  either  to  a  discharge  (weeping),  with  subsequent  crusting, 
or  to  the  deposition  of  plastic  material.  The  most  constant, 
annoying,  and  troublesome  symptom  is  the  itching,  or,  at  times, 
burning,  which  varies  from  that  which  is  simply  annoying  to 
that  which  is  almost  unendurable. 

Ezcema  runs  its  course  either  as  an  acute  affection,  lasting  a 
few  weeks,  not  to  return,  or  to  return  acutely  at  wide  intervals, 
or,  as  is  miich  more  frequently  the  case,  it  assumes  a  chronic 
state,  continuing  with  more  or  less  variations  for  months,  years, 
or  even  a  life-time.  It  may  appear  upon  any  portion  of  the 
body  or  involve  the  whole  integument  {eczema  universale). 
The  varieties  are  named  in  the  order  the  lesions  assume  at 
their  commencement. 

Eczema  Erythematosum. — An  erythema  or  redness  of  the 
surface,  with  a  yellow  tinge.  The  size  of  the  macule  may  be 
very  small  or  quite  extensive,  with  irregular  outlines.  There 
may  be  slight  swelling  of  the  patch,  but  no  discharge  occurs  un- 
less it  be  where  two  surfaces  come  into  contact  {eczema  inter- 
trigo), as  about  the  genitalia.  Cases  without  discharge  are 
covered  after  a  few  days  with  a  thin  film  of  dry,  exfoliating  epi- 


ECZEMA.  735 

dermis  or  scale  (eczema  squamosum).  When  a  discharge  (weep- 
ing) or  moisture  occurs,  it  is  followed  with  more  or  less  crusting. 
Intense  itching  is  a  constant  symptom.  The  variety  occurs  most 
frequently  on  the  face,  the  back  of  the  neck,  and  the  genitalia. 

Eczema  Papulosum,  or  Lichen  Simplex. — This  variety  of 
eczema  appears  in  the  form  of  small,  rounded  papules,  the  size 
of  a  pin-head,  of  bright-red  or,  at  times,  dark-red  color;  they 
may  be  either  discrete  or  confluent.  In  some  cases  all,  while 
in  others  a  greater  or  less  number,  of  the  papules  pass  into 
vesicles  and  run  much  the  same  course  as  vesicular  eczema. 
The  itching  is  of  the  most  intense  character,  leading  to  severe 
scratching,  by  which  the  summits  of  the  papules  are  torn, 
causing  them  to  bleed,  the  blood  forming  dark-red  crusts. 
The  arms  and  legs  are  most  often  involved. 

Eczema  Vesiculosum.- — This  variety  begins  with  burning, 
pain,  redness,  and  swelling,  followed  by  the  eruption  of  an 
immense  number  of  minute  vesicles,  either  discrete  or  con- 
fluent, rapidly  distending  with  a  clear  or  yellowish  fluid  and 
attended  with  intense  itching.  Soon  the  vesicles  rupture, 
the  fluid  rapidly  diffusing  over  the  surface  and  drying  into  yel- 
lowish, honey-like  crusts.  New  crops  of  vesicles  soon  follow,  or 
if  subsequent  vesications  do  not  occur,  the  fluid  rapidly  diffuses 
over  the  excoriated  surface,  which  also,  in  turn,  dries  into  large, 
yellowish  crusts.  After  a  variable  time  the  various  symptoms 
gradually  subside.  Intense  itching  is  the  most  prominent  sub- 
jective symptom,  and  gives  rise  to  an  irresistible  desire  to 
scratch.  All  portions  of  the  body  are  liable  to  this  variety  of 
eczema,  the  most  frequent  location,  however,  being  the  face, 
and  when  occurring  in  this  region  in  children  is  commonly  known 
as  crusta  lactea.  The  affection  is  very  chronic  and  recurrences 
are  common.      It  often  terminates  in  eczema  rubrum. 

Eczema  Pustulosum,  or  Eczema  Impetiginosum. — This  form 
usually  begins  as  vesicular  eczema,  the  fluid  rapidly  changing 
to  pus.  After  a  short  period,  during  which  the  pustules  have 
increased  in  size,  they  burst  and  the  escaped  fluid  forms  thick, 
greenish-yellow  crusts,  which,  in  turn,  rapidly  dry  and  fall  off, 
or  crumble  away.     The  location  of  this  variety  is  most  usually 


736  ECZEMA. 

Upon  the  scalp  and  face.  It  is  observed  most  often  in  poorly- 
nourished  and  unclean  children  and  is  stubborn  to  treatment. 
Itching  is  a  prominent  symptom. 

Eczema  Rubrum. — This  is  a  variety  only  from  a  clinical  stand- 
point. It  may  result  from  any  of  the  foregoing  varieties.  The 
surface  of  the  skin  is  inflamed  and  infiltrated,  red,  moist,  and 
weeping,  the  profuse  serum  rapidly  drying  into  thick,  yellowish, 
greenish,  or  brownish  crusts,  the  color  depending  upon  the  char- 
acter of  the  fluid,  which  may  be  serum,  pus,  or  blood  from  the 
exposed  and  lacerated  corium.  The  crusts  adhere  closely  and 
firmly  to  the  part,  and  unless  removed  by  mechanical  means 
may  remain  indefinitely,  the  disease  pursuing  its  course  beneath. 
Eczema  rubrum,  or  madidans,  "  presents  two  appearances — as  it 
occurs  with  its  crust,  and  as  it  exists  without  this  covering.  In 
the  one  case  the  skin  itself  is  altogether  obscured  by  a  dirty, 
yellowish,  or  brownish  crust;  in  the  other  the  skin  presents  a 
bright  or  violaceous  red,  punctate,  wounded  surface,  deprived 
in  great  part  of  its  epidermis,  and  exuding  a  scanty  or  profuse, 
clear  or  opaque,  syrupy,  yellowish  fluid.  Sometimes  this  is 
streaked  with  blood."  The  itching  and  burning  are  severe.  It 
may  develop  upon  any  portion  of  the  body,  but  is  most  com- 
monly seen  upon  the  legs,  particularly  in  elderly  people,  and  on 
the  face  in  infants.  Its  course  is  chronic  and  tends  to  increase 
in  severity. 

Eczema  Squamosum. — This  is  also  a  clinical  variety.  It 
occurs  as  the  terminal  stage  of  the  erythematous,  vesicular, 
pustular,  or  papular  varieties  of  the  affection,  but  more  particu- 
larly the  first  named.  A  typical  case  presents  itself  in  the  form 
of  variously  sized  and  shaped  reddish  patches,  which  are  dry,  or 
more  or  less  scaly,  the  skin  being  more  or  less  infiltrated  or 
thickened.  When  occurring  at  the  flexures  of  the  body  the 
skin  is  liable  to  become  fissured.      Its  course  is  usually  chronic. 

Eczema  Fissum,  or  Rimosum. — A  clinical  variety,  in  which, 
during  the  progress  of  the  erythematous,  vesicular,  or  pustular 
varieties  of  eczema,  cracks  or  fissures  result  when  the  lesion 
occurs  upon  regions  subject  to  constant  motion,  such  as  be- 
tween  the   fingers,    toes,    nates,    and   the   various   joints.     At 


ECZEMA.  737 

times  the  fissures  are  extensive  and  deep,  and  of  a  bright-red 
color,  showing  the  true  skin,  and  intensely  painful  upon  motion. 
Chapped  hands  are  typical  instances  of  fissured  eczema. 

Eczema  Sclerosum. — This  clinical  variety  of  eczema,  occur- 
ring most  commonly  on  the  palms,  soles,  and  finger-tips,  is  char- 
acterized by  hypertrophy  of  the  papillae,  showing  itself  as  hard, 
thickened,  infiltrated,  localized  patches,  which  are  very  liable 
to  crack  (eczema  fissum). 

Eczema  Verrucosum,  or  Papillomatosum,  differs  from  the 
foregoing  in  that  the  thickened,  infiltrated  patch  has  a  warty, 
verrucous  appearance.      Its  course  is  chronic. 

Acute  and  Chronic  Eczema. — The  line  which  divides  these 
two  conditions  is  drawn  by  means  of  the  clinical  and  patho- 
logical features.  The  course  of  eczema,  in  the  majority  of  in- 
stances, is  chronic.  It  may  be  said  that  so  long  as  the  general 
inflammatory  symptoms  are  high  and  the  secondary  changes 
slight,  the  affection  is  acute,  and  that  when  the  process  has 
settled  itself  into  a  definite  line  of  action,  continually  repeating 
itself  and  accompanied  by  secondary  changes,  it  is  chronic. 

Diagnosis. — The  many  varieties  in  which  eczema  manifests 
itself  renders  the  diagnosis  a  matter  of  importance.  The  follow- 
ing characteristic  features  of  eczema  are  of  value  in  arriving  at  a 
diagnosis:  Inflammation,  redness,  swelling,  edeTna,  thickening 
from  cell  infiltration,  serous  exudation  followed  by  crusting,  on 
the  removal  of  which  a  moist  surface  is  exposed,  absence  of  a 
sharp  line  of  demarcation  between  the  diseased  area  and  the 
healthy  skin,  polymorphism  of  the  lesions,  and  marked  itching 
and  burning. 

Erysipelas  may  be  confounded  with  erythematous  or  vesicular 
eczema.  The  points  of  difference  are  the  fever  and  other  general 
disturbances.  The  deep-seated  inflammation  of  the  skin, 
rapidly  spreading,  with  heat,  swelling,  and  edema  without 
moisttire,  giving  the  surface  a  deep-red,  shining,  and  tense 
appearance,  are  characteristic  of  erysipelas  and  serve  to  dis- 
tinguish it  from  eczema. 

Herpes  zoster  may  be  confused  with  vesicular  eczema,  but  in 
the  former  the  eruption  is  preceded  by  neuralgic  pains  over  the 
47 


738  ECZEMA. 

affected  areas,  vesicles  form  in  groups  along  the  course  of  super- 
ficial nerves  and  are  large  and  tense,  showing  no  tendency  to 
spontaneous  rupture,  the  eruption  is  unilateral,  and  the  course 
is  definite;  all  of  which  features  are  absent  in  vesicular  eczema. 

Scabies  often  resembles  eczema,  especially  those  cases  in 
which  the  resulting  dermatitis  is  severe.  A  distinction  here  is 
of  the  utmost  importance  as  the  apparent  eczema  may  persist 
indefinitely  unless  the  true  cause  be  promptly  ascertained.  In 
scabies  the  eruption  is  distributed  to  the  flexor  surfaces  of  the 
body,  the  webs  of  the  fingers,  axillae,  mammary  glands,  buttocks, 
penis  and  inside  surfaces  of  the  legs  and  thighs;  the  face  is 
exempt  except  in  nursing  infants;  the  itching  is  worse  at  night; 
there  is  a  history  of  contagion;  and  the  burrows  and  itch-mite 
may  be  detected.  Eczema  has  no  characteristic  distribution, 
is  not  contagious;  the  itching  is  constant,  and  there  are  no 
burrows  or  itch-mites. 

Impetigo  contagiosa  may  be  at  times  mistaken  for  pustular  ec- 
zema, the  points  of  distinction  being:  In  impetigo  there  is  a 
history  of  contagion;  the  lesions  first  appear  as  discrete  vesicles 
or  blebs,  the  contents  of  which  rapidly  become  purulent  and 
soon  flat,  loosely-attached  crusts  form.  The  lesions  are  super- 
flcial  and  disappear  within  one  or  two  weeks.  Itching  is  very 
slight.  In  eczema  there  is  a  diffuse  deep  inflammatory  base; 
the  affection  is  non-contagious,  and  the  course  very  chronic. 

Sycosis  vulgaris  may  be  distinguished  from  eczema  by  its 
localization  to  the  hair-follicles,  the  interfollicular  skin  being 
free,  and  by  its  great  tendency  to  recur. 

Psoriasis  may  be  readily  differentiated  from  eczema  by  its 
location  (elbows,  knees,  scalp),  the  presence  of  round,  sharply 
marginated  patches  abundantly  covered  with  imbricated, 
silvery,  mother-of-pearl  scales,  the  absence  of  infiltration, 
thickening,  and  discharge  so  characteristic  of  eczema,  and  the 
very  chronic  course. 

Tinea  circinata  and  squamous  eczema  may  simulate  each 
other.  The  former  is  characterized  by  its  circinate,  sharply 
defined  patches,  clearing  in  the  center  and  spreading  on  the 
periphery,  its  contagious  nature,  and  the  presence  of  the  tricho- 


ECZEMA.  739 

phyton  fungus  in  the  scales,  demonstrable  by  the  microscope. 
In  eczema,  the  patches  are  irregular,  not  well  defined,  and  do  not 
tend  to  clear  in  the  center.  It  is  not  contagious  and  there  is  no 
fungus  present  in  the  scales. 

Seborrhea  of  the  scalp  and  squamous  eczema  of  the  same  region 
closely  resemble  each  other.  In  eczema,  however,  the  skin  is 
more  or  less  red,  inflamed,  and  thickened,  and  the  scales  larger, 
less  abundant  and  less  greasy  and  drier  than  seborrhea.  In 
eczema  the  scales  are  usually  seated  in  a  circumscribed  patch, 
while  in  seborrhea,  as  a  rule,  they  cover  the  scalp  uniformly. 
Itching  occurs  with  both  disorders.  The  history  of  the  two 
affections  should  be  of  material  aid  in  rendering  the  diagnosis 
clear;  still,  however,  in  many  cases  the  diagnosis  is  difficult. 
Both  are  frequent  affections. 

Treatment. — There  is  no  specific.  The  indications  are  to  re- 
move the  cause  if  possible,  to  maintain  the  general  health,  and 
to  apply  such  substances  to  the  diseased  area  as  will  induce 
involution  of  the  inflammatory  process.  The  diet  should  be 
given  most  careful  attention  as  frequently,  particularly  in 
children,  errors  in  this  direction  are  most  potent  etiologic  factors. 
Tea,  coffee,  alcoholic  beverages,  sugar,  candies,  pastries, 
starchy  foods,  fried  meats,  condiments,  etc.,  should  be  inter- 
dicted or  at  least  reduced  to  a  minimum.  Substances  which 
the  patient  is  aware  do  not  agree  with  him  should  of  course  be 
avoided.  Fresh  air  and  moderate  exercise  are  essentials  in 
the  treatment  together  with  attention  to  the  secretions,  par- 
ticularly of  the  kidneys.  Sluggish  action  of  the  bowels  should 
be  avoided  by  the  use  of  such  mineral-spring  waters  as  the 
Hunyadi  Janos,  or  a  morning  dose  of  magnesium  sulphate.  The 
"acid  mixture  of  iron"  is  of  great  value  in  this  connection: 

I^.     Ferri  sulphatis gr.  viii  .  5 1  gm. 

Magnesii  sulphatis §iss  47 .  gm. 

Acid  sulphuric,  dilut.  .  .  .    ttlIxxx  5  .  c.c. 
Tr.  cardamom,  comp. 

q.  s.  ad  f  giv  120.  c.c. 

M.  S. — One    tablespoonful    in   water,    half    an  hour  before 
breakfast. 


740  ECZEMA. 

For  children,  equal  parts  of  aromatic  syrup  of  rhubarb  and 
castor  oil  make  an  excellent  laxative  mixture.  The  addition  of 
magnesia  to  syrup  of  rhubarb  may  also  be  employed.  Calomel 
and  soda  is  a  useful  combination. 

If  the  urinary  secretion  be  small  and  the  urine  heavy,  full 
doses  of  potassium  actate  and  large  draughts  of  water  should 
be  used.  If  either  a  rheumatic  or  gouty  tendency  exists,  the 
salicylates,  lithium  salts,  or  colchicum  should  be  employed. 
If  there  is  any  scrofulous  or  tubercular  tendency  cod-liver  oil 
and  syrup  of  iodid  of  iron  should  be  prescribed  in  addition  to 
fresh  air,  sunlight,  regulated  exercise,  etc.  In  anemic  individ- 
uals, iron,  quinin,  strychnin,  mineral  acids,  syrup  of  the  hypo- 
phosphites,  and  small  doses  of  corrosive  sublimate  are  indicated. 
Arsenic  is  usually  contraindicated  in  eczema,  its  field  of  useful- 
ness being  limited  to  those  cases  occurring  in  weak,  anemic, 
debilitated,  neurotic  individuals.  It  has  no  direct  bearing 
upon  the  disease  itself.  Potassium  iodid,  internally,  frequently 
aids  in  reducing  the  infiltration  in  chronic  thickened  eczemes 
even  in  the  absence  of  syphilis. 

Locally,  the  first  step  in  the  treatment  is  to  remove  all  forms 
of  existing  irritation.  It  may  be  stated  as  a  principle,  that 
nothing  irritant  is  ever  to  be  applied  to  the  surface  in  acute 
eczema  and  that  in  chronic  eczema,  stimulation  is  indicated. 
Soap  and  water  are  to  be  avoided  on  areas  the  seat  of  acute 
eczema.  For  cleansing  purposes,  water  containing  boric  acid, 
bran,  starch,  or  oatmeal,  may  be  employed.  In  chronic, 
thickened,  and  indurated  eczema,  soap  is  often  of  value  as  a 
stimulant.  Crusts  and  scales  are  nearly  always  present  in 
eczema  and  must  first  be  removed  to  obtain  the  best  results 
from  local  applications.  This  may  be  readily  accomplished 
by  saturation  with  oily  preparations,  a  starch  or  other  mild 
poultice,  a  saturated  solution  of  boric  acid,  or  dilute  boro- 
glycerin.  Pastes  and  ointments  may  be  easily  removed  by 
first  softening  with  olive  oil,  sweet  oil,  or  petrolatum.  Soap  and 
water  should  not  be  used  for  either  purpose. 

Acute  Eczema. — If  the  type  of  disease  is  vesicular,  dusting 
powders  such  as  magnesium  carbonate,  boric  acid,  bismuth  sub- 


ECZEMA.  741 

nitrate,  starch,  zinc  oxid,  talcum,  etc.,  may  be  employed  with 
advantage  in  the  early  stage.     The  following  may  also  be  used : 

I^.     Pulv.  camphorae 3  j  4  •  g^i. 

Zinc  oleat 3ij  8  .  gm. 

Pulv.  amyli 5 j  32.  gm. 

M.  S. — Dusting  powder. 

J.  C.  White  recommends  bathing  the  part  with  lotto  nigra  full 
strength  or  diluted  with  lime-water,  applied  by  means  of  a 
sponge  or  a  piece  of  cloth  for  ten  or  fifteen  minutes  at  a  time, 
and  at  intervals  of  a  few  hours  or  longer,  the  sediment  being 
allowed  to  dry  on  the  skin,  after  which  oxid  of  zinc  ointment 
should  be  gently  rubbed  over  the  part.  As  a  rule,  the  itching 
and  burning  are  promptly  relieved  and  the  affection  often 
arrested. 

I^.     Hydrarg.  chlor.  mit gr.  viii  o  .  5  gm. 

Liquor  calcis f  §i  30 .      c.c. 

M.  S. — Lotio  Nigra.     Apply  locally  as  directed. 

Stel wagon  employs  the  boric-acid  lotion,  15  gr.  (i  gm.)  to 
the  ounce  (30  c.c),  followed  by  applications  of  zinc  oxid  oint- 
ment in  vesicular  eczema  and  the  following  compound  lotion 
in  erythematous  and  papular  types : 

I^.     Acidid.  boric 5ii  8.  gin. 

Acid,  carbolici 5ss  2  .  gm. 

Glycerin tt[x  to  xxx  o  .  65  to  2  .  c.c. 

Aquae q.  s.  ad  Oss  250.  c.c. 

M.  S. — Apply  locally  twice  daily. 

This  may  be  used  alone  or  followed  by  an  ointment  or  a 
dusting  powder.  Lotions  containing  an  excess  of  the  substance 
in  solution  are  of  value  by  the  sediment  they  leave  behind, 
which  acts  as  a  dusting  powder.  The  calamin  and  zinc  oxid 
lotion  may  be  taken  as  an  example: 
I^.     Calamin, 

Zinc  oxid aa    5ii  to  iv  8 .  to  1 6 .  gm. 

Liquor  calcis f  §ii  60.  c.c. 

Aquae  vel  solut.   acid. 

boric  saturat.q.  s.  ad  Oss  250,  c.c. 

M.  S. — Apply  locally  several  times  daily  (Stelwagon). 


742  ECZEMA. 

The  following  lotion  is  employed  extensively  in  acute  cases 
by  Hartzell: 

I^.      Resorcin 3ss  2 .  gm. 

Bismuth  subnitrat 3ii  8  .  gm. 

Glycerin 3ii  8  .  c.c. 

Liq.  calcis q.  s.  ad  f  5iv  120.  c.c. 

M.  S. — Apply  locally  twice  daily. 

Some  cases  do  better  on  ointments  such  as — 

I^.      Zinci  oleat 5iv  16 .  gm. 

Olei  oliv^ f  5iv  "  16.  c.c. 

M.  Ft.  unguentum. 

S. — Apply  locally  twice  daily. 

Or,  bismuth  oleate,  made  according  to  the  following  formula 
of  McCall  Anderson: 

I^.      Bismuthi  oxidi 5j  4.        gm. 

Acidi  oleici §  j  30 .        gm. 

Cerse  albae oiij  12 .       gm. 

Vaselini 5ix  36.       gm. 

01.  rosce vr[ij  0.12  c.c. 

M.  S. — Use  locally  as  directed. 

If  the  discharge  be  excessive,  the  following  formula  of  Bar- 
tholow  is  valuable: 

I^.     Plumbi  acetat 3ss  16.  gm. 

Pulv.  camphoras gr.xv  i .  gm. 

01.  araiygdal. f  Bij  60.  c.c. 

Cerat.  flav 5j  32  .  gm. 

M.  S. — For  local  application. 

Pastes  are  often  of  value,  of  which  Lassar's  paste  may  be 
taken  as  a  type: 

I^.     Pulv.  amyli, 

Pulv.  zinci  oxid aa    oii  8.  gm. 

Petrolat 5ss  16.  gm. 

M.  S. — Apply  to  affected  area  twice  daily;  using  sweet  oil 
or  petrolatum  to  remove  the  same  before  applying  fresh  paste. 

This  may  be  used  alone  or  in  combination  with  boric  acid  or 
salicylic  acid  or  it  may  be  rendered  more  soft  by  the  addition  of 
an  equal  quantity  of  petrolatum.      Diachylon  ointment,  made 


ECZEMA.  743 

by  the  formula  of  Hebra  or  by  melting  4  parts  of  lead  plaster 
and  2  or  3  parts  of  olive  oil,  is  also  very  efficacious. 
In  pustular  eczema,  the  following  is  of  great  benefit: 

I^.      Hydrarg.  ammoniat.  .  .  .     gr.  xx  1.3  gm. 

Petrolat oi  32 .     gm. 

M.  S. — Apply  locally. 

For  eczema  papulosum  the  following  lotions  are  particularly 
valuable : 

I^.      Acidi  carbolici 5  j  to  ij  4  .  to  8  .  gm. 

Glycerini f  3iv  16.  c.c. 

Alcoholis. f  oiv  to  vj  r6  to  24.  c.c. 

Aquae  destil. ..  .q.  s.  ad  Oj  ad  480.  c.c. 
M.  S. — Apply  locally  (Duhring). 

Or— 

I^.     Thymol gr.xv  i.  gm. 

Alcoholis f§j  30.  c.c. 

Aquae  destil foj  3°-  c.c. 

M.  S. — Apply  locally. 

To  relieve  the  itching  incident  to  acute  eczema,  carbolic  acid, 
menthol,  and  preparations  of  tar  may  be  added  to  the  preceding 
formulas  but  in  very  weak  strength  in  order  to  avoid  inducing 
additional  irritation. 

After  the  disappearance  of  the  acute  symptoms,  the  applica- 
tions should  be  more  stimulating  and  sho^jld  include  carbolic 
acid,  thymol,  tar,  oil  of  cade,  and  similar  substances.  It  is  to  be 
remembered,  however,  that  the  more  chronic  the  affection  and 
the  less  violent  the  inflammatory  symptoms  the  more  success- 
ful is  tar  in  this  disease.  Furthermore,  it  should  be  borne  in 
mind  that  the  dosage  of  external  medication  is  subject  to  great 
variations  in  different  individuals  and  it  is  always  best  to  begin 
with  a  very  weak  ointment  or  lotion,  watching  the  effects  while 
the  strength  is  being  increased.  Unless  this  precaution  is  taken 
the  disease  is  likely  to  be  aggravated.  The  following  is  of 
value  in  subacute  cases: 

I^.      Liq.  carbonis  detergent..     3ss  to  ii  16.  to  64.  c.c. 

Aquae Oi  480.  c.c. 

M.  S. — Poison;  for  external  use  only. 


744  ECZEMA. 

Duhring  considers  the  following  one  of  the  most  elegant  of 
the  tar  ointments: 

I^.      Olei  cadini f  3iss  6 .     c.c. 

Cerati  simplicis 5j  32  .     gm. 

01.  amygdal  amar gtt.  x  0.6  c.c. 

M.  Ft.  ungt. 

S. — Apply  as  directed. 

Or— 

I^.      Picis  liquidae. f  5j  4.  c.c. 

Glycerin! f  5j  4.  c.c. 

Alcoholis f  3  vj  24  .  c.c. 

01.  amygdal,  amar gtt.  xv  i .  c.c. 

M.  S. — To  be  rubbed  firmly  into  the  skin. 

The  following  is  Bulkley's  valuable  "liquor  picis  alkalinus" : 

I^.     Picis  liquidae f  3ij  8.  c.c. 

Potassae  causticae 3j  4.  gm. 

Aquae  destillatae f  3v  20.  c.c. 

The  potash  to  be   dissolved  in  water  and  gradually  added 
to  the  tar  with  rubbing  in  a  mortar. 
M.  S. — To  be  used  diluted. 

Chronic  Eczema. — In  this  variety  the  treatment  varies  accord- 
ing as  to  whether  the  affected  area  is  weeping  or  is  dry,  hard, 
and  sclerosed.  The  weeping  and  discharging  eczemas  while 
chronic  as  regards  time  are  usually  acute  in  type  and  require 
sedative  or  moderately  stimulating  applications  until  the  dis- 
charge has  been  reduced.  In  the  dry,  infiltrated,  and  thickened 
varieties,  stimulation  is  necessary.     The  following  is  of  value: 

I^.      Olei  cadini 3j  4.       gm. 

Acid,  salicyl gr.  x  0.65  gm. 

Pulv.  amyli, 

Pulv.  zinc  oxidi aa    3ii  8 .        gm. 

Petrolat 3iv  16 .       gm. 

M.  S. — Apply  locally  twice  daily. 

The  following  ointment,  technically  known  as  "  unguenium 
diachyli  alhi  of  Hebra,"  has  been  successful  in  a  number  of  cases 
of  chronic  eczema  of  the  legs.     The  formula  is: 


TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF  ECZEMA.    745 

I^.      Emplast.  plumbi, 

Vaselini aa    5j  aa  32  .  gm. 

01.  lavandulae q.  s.  q.  s. 

Dissolve  with  heat  and  stir  till  cold. 
M.  S. — Apply  on  strips. 

The  application  of  an  elastic  webbing  bandage  (not  the 
ordinary  rubber  bandage)  to  the  affected  leg  in  cases  of  eczema 
unattended  by  discharge  is  often  of  great  benefit.  The  support 
afforded  by  a  gelatin  dressing  commends  its  use  but  it  is  con- 
traindicated  when  there  is  any  active  discharge.  The  following 
is  used  extensively: 

I^.      Zinc,  oxid, 

Gelatin • aa     30  parts 

Glycerin 50  parts 

Aquae 90  parts 

M.  S. — The  application  is  melted  on  a  water-bath  and  the 
temperature  is  allowed  to  fall  until  it  is  near  that  of  the 
body,  after  which  it  is  thickly  painted  on  the  already  cleaned 
affected  area.  It  is  then  strewn  with  a  powder  or  absorbent 
wool  dabbed  on  to  facilitate  the  hardening  process  (Whitfield). 

Da  Costa  claims  to  have  had  excellent  results  in  the  treatment 
of  eczema  rubrum  from  the  internal  administration  of  the  solu- 
tion of  arsenic  and  the  iodid  of  mercury  (Donovan's  solution), 
n^ii  to  V  (0.12  to  o.  3  c.c),  in  water  after  meals  and  the  local 
application  of  the  following: 

I^.      Ung.  plumbi  subacet ...  .     5iv  16.     gm. 

Acid,  carbolici  cryst gr.  iij  o.  2  gm. 

Petrolat oiv  16 .     gm. 

M.  S. — Apply  freely  on  muslin  strips. 

TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES 

OF  ECZEMA. 

The  principles  upon  which  eczema  is  treated  admit  of  no 
variation,  no  matter  in  what  region  the  disease  is  encountered, 
but  the  form  of  irritation  to  which  the  affection  is  usually  due 
differs  in  different  parts  of  the  body  and  requires  more  than 
passing  mention. 


746     TREATMENT  OF  SPECIAL  EORMS  AND  VARIETIES  OF  ECZEMA. 

Universal  eczema  arises  either  as  the  result  of  grave  internal 
disorders,  especially  in  children,  or  from  generalized  irritation 
such  as  accompanies  the  parasitic  affections  and  attends  certain 
occupations.  Obviously  the  removal  of  the  cause  in  these  cases 
brings  about  subsidence  of  the  eczema. 

Eczema  capitis  is  either  erythematous,  vesicular,  or  pustular 
in  character.  If  the  first  named,  it  at  once  tends  to  become 
chronic,  settling  into  the  variety  known  as  eczema  squamosum, 
often  involving  the  entire  scalp  and  accompanied  with  intense 
itching.  The  pustular  variety  is  the  more  common  form, 
occurring  upon  the  scalp  of  children  and  young  adults,  existing 
as  a  few  patches,  or,  what  is  more  frequent,  involving  the  entire 
scalp.  The  pustules  soon  rupture,  the  liquid  drying  into 
greenish-yellow  crusts,  often  covering  the  whole  scalp  with  a 
cap  of  crust.  The  hair  becomes  matted  and  caked,  the  seba- 
ceous secretions  collect,  and  if  the  part  is  not  cleansed,  becomes 
offensive.  In  severe  cases  of  pustular  eczema  of  the  scalp 
enlargement  of  the  lymphatic  glands  of  the  back  of  the  neck 
and  of  those  behind  the  ear  occur;  but  they  never  suppurate. 
Pediculi  are  frequently  associated  with  eczema  capitis  hi  chil- 
dren, either  as  a  primary  cause  or  a  result  of  the  matted  condi- 
tion of  the  hair  which  constitutes  a  favorable  habitat  for  them. 
Care  should  always  be  taken  not  to  confuse  eczema  of  the  scalp 
with  psoriasis,  seborrhea,  syphilis,  tinea  favosa,  and  tinea 
tonsurans. 

Treatment. — In  the  pustular  variety  the  crusts  should  first 
be  removed  by  saturation  with  olive  oil  or  oil  of  sweet  almond 
and  washing  with  warm  water  and  soap,  or  the  use  of  a  starch 
poultice  or  a  25  per  cent,  solution  of  boroglycerin.  It  should 
be  borne  in  mind  that  neglect  is  responsible  for  a  great  many  of 
these  cases.  Da  Costa  recommends  the  following  application 
after  removal  of  the  crusts: 


I^.      Hydrargyri  chlor.  mitis..  gr.  xx  1.3  gm. 

Acid,  carbol.  cryst gr.  iij  0.2  gm. 

Petrolat 5  j  32  .     gm. 

M.  S. — Apply  thoroughly. 


TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF  ECZEMA.    747 

In  cases  associated  with  pediculi  or  succeeding  impetigo  con- 
tagiosa the  following  is  of  great  benefit : 

I^.      Hydrargyri  ammoniat    gr.  x  to  xx  o .  65  to  i  .  3  gm. 

Adipis  benzoat 5j  32.     gm. 

M.  S. — Apply  locally. 

For  the  squamous  variety  of  the  scalp,  the  following  formula, 
recommended  by  Duhring  is  excellent: 

■  I^.      Picis  liquidas f  5j  4     c.c. 

Glycerini f  3  j  4  •  c.c. 

Alcoholis f  ovj  24.  c.c. 

01.  amygdala  amar gtt.  xv  i .  c.c. 

M.  S. — Diluted  or  full  strength,  rubbed  thoroughly  into  the 
scalp. 

Other  applications,  such  as  boric-acid  lotion,  oxid  of  zinc  oint- 
ment, etc.,  previously  advised,  may  also  be  used  with  the  excep- 
tion of  the  pastes,  which  are  extremely  difficult  to  remove  from 
the  hair.  A  word  of  caution  may  be  given  regarding  resorcin 
lotions  in  eczema  of  the  scalp.  In  brunettes  such  applications 
may  be  used,  but  in  blondes  the  hair  is  apt  to  assume  various 
shades  as  a  result  of  the  application. 

In  all  cases  cleanliness  is  essential.  The  diet  should  be  care- 
fully regulated  and  tonics  should  be  administered  if  the  patient's 
condition  is  one  of  general  debility. 

Eczema  Faciei. — In  this  location  the  affection  may  be  either 
acute  or  chronic.  In  adults  the  erythematous  variety  is  fre- 
quently encountered  in  patches  about  the  forehead  and  cheeks. 
It  usually  results  from  irritation  such  as  accompanies  exposure 
to  heat  and  cold  and  contact  with  strong  soaps,  etc.  Eczema 
of  the  face  is  more  common  in  children,  however,  the  varieties 
being  the  vesicular  and  pustular.  It  is  seen  on  the  forehead, 
nose,  and  upper  lip,  and  is  associated  with  severe  itching.  The 
primary  cause  in  most  cases  is  to  be  found  in  disturbances  of 
digestion  although  the  condition  may  be  greatly  aggravated 
by  attempts  at  treatment  by  members  of  the  family. 

Treatment. — The  cause  should  be  promptly  removed.  The 
difficulty   with   which   determination   of  the  cause  is  attended 


748    TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF  ECZEMA. 

shoiild  lead  the  physician  to  regulate  the  diet,  as  already 
given,  and  interdict  the  local  use  of  soap  and  water  routinely. 
The  application  of  a  mild  sedative  lotion  such  as  a  saturated 
solution  of  boric  acid  should  be  prescribed  at  first  until  the  true 
condition  of  the  disease  is  asserted.  In  erythematous  eczema 
of  the  face  lotions  seem  most  beneficial;  in  vesicular  and  pus- 
tular forms,  soft  ointments  and  pastes  are  valuable.  Late  in  all 
forms  of  facial  eczema  pastes  are  of  great  service.  The  follow- 
ing is  also  useful: 

I^.      Zinc,  oleat 5i  4*  gm. 

Petrolat Si  32.  gm. 

M.  S. — Apply  locally. 

Eczema-  Lahiorum. — Eczema  attacks  the  lips,  either  alone  or 
in  connection  with  other  parts  of  the  face.  One  or  both  lips  may 
be  affected.  The  irritation  of  the  tooth  brush  or  tooth  powder 
may  be  the  cause.  The  symptoms  are  swelling,  redness,  heat, 
infiltration,  slight  scaliness,  and  fissures.  The  affection  may  be 
in  the  skin  around  the  border  of  the  mouth,  or  the  vermilion 
and  mucous  membrane  of  the  lips.  The  mouth  may  be  con- 
tracted and  the  lips  partly  glued  together  by  the  exudation  and 
crusts.  Eczema  labiorum  may  be  confounded  with  herpes 
labialis  and  syphilis. 

Treatment. — This  is  very  difficult  and  inconvenient  to  the  pa- 
tient. Among  the  remedies  at  times  successful  may  be  men- 
tioned silver  nitrate,  potassium  nitrate,  carbolic  acid,  boric  acid, 
or  tar  in  solution  or  ointment,  and  flexible  collodion.  A  com- 
bination of  boric  acid,  acetanilid,  and  bismuth  is  often  of  value. 
Tragacanth,  acacia,  and  gelatin  paints  are  also  used  and  should 
be  applied  with  the  lips  apart,  otherwise  the  dressing  cracks 
when  the  mouth  is  opened. 

Eczema  Palpebrarum. — This  is  a  rather  common  occurrence 
in  scrofulous  children,  showing  itself  along  the  edge  of  the  eye- 
lids. It  is  frequently  accompanied  by  conjunctivitis.  It  may 
be  due  to  the  congestion  that  attends  eye-strain.  Pediculosis 
ciliorum  is  an  occasional  cause.  Pustules  form  at  the  openings 
of  the   hair  follicles   and  the  lids   become   crusted.     Swelling, 


TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF  ECZEMA.    749 

redness,  and  itching  are  present  and  unless  the  parts  are  fre- 
quently cleansed,  the  lids  will  become  glued  together. 

Treatment. — The  discharge  incident  to  any  existing  conjunc- 
tivitis should  be  removed  and  any  ocular  condition  present 
should  be  treated.  Yellow  oxid  of  mercury,  gr.  i  (0.065  g^^-). 
in  petrolatum,  5ii  (8  gm.),  rubbed  into  the  roots  of  the  eye- 
lashes every  night  is  very  beneficial.  The  oleate  of  zinc  and 
the  glycerite  of  tannic  acid  are  also  valuable. 

In  severe  cases  the  plan  recommended  by  McCall  Anderson 
should  be  pursued.  It  consists  in  the  extraction  of  the  eye- 
lashes and  touching  the  edges  of  the  lids  with  a  solution  of 
potassium  in  water,  10  gr.  to  the  ounce.  The  edges  should 
be  carefully  dried  and  the  lid  everted,  a  very  small  quantity  on 
a  delicate  brush  being  applied,  immediately  neutralizing  the 
alkali  with  acetic  acid  or  vinegar. 

Eczema  Narium. — This  also  occurs  most  often  in  children 
and  appears  as  the  pustular  form  of  the  disease.  Nasal  catarrh 
and  general  malnutrition  are  the  most  important  etiologic 
factors.  These  should  first  receive  attention,  after  which 
the  treatment  advised  for  pustular  eczema,  elsewhere,  is 
applicable. 

Eczem.a  Barhce. — Eczema  of  the  beard  is  characterized  by  the 
formation  of  extensive  pustules,  showing  a  preference  for  the 
skin  about  the  hairs,  drying  as  yellowish  or  greenish  crusts, 
matting  the  hairs  together  and  adhering  to  the  parts.  The 
affection  may  be  confined  to  the  hairy  portions  of  the  face,  or 
extend  to  other  regions  of  the  face,  localized  or  general,  acute 
or  chronic. 

Eczema  barbae  in  its  general  features  somewhat  resembles 
both  tinea  sycosis  and  sycosis  non-parasitica,  but  sycosis  is  an 
inflammation  of  the  hair-follicles  only  and  is  rarely  associated 
with  crusting,  while  crusting  is  abundant  in  eczema. 

Treatment. — The  hair  should  be  kept  very  short  by  clipping 
with  scissors;  when  the  inflammation  has  subsided  somewhat, 
shaving  closely  is  indicated.  Sedative  lotions  and  ointments 
are  to  be  used  at  first.  The  crusting  should  be  removed  by  oil 
or  petrolatum  but  not  by  soap  and  water,  if  the  inflammation 


750    TREATMENT  OE  SPECIAL  EORMS  AND  VARIETIES  OF  ECZEMA. 

is  acute.      In  chronic  cases  the  following  ointment  should  be 
applied  after  cleansing  and  shaving  the  beard: 

I^.      Hydrargyri  ammoniat. .  .    gr.  xv  to  xxx  i .  to  2  .  gm. 

Sulphur,  prsecipitati oss  to  j  2  .  to  4  .  gm. 

Petrolat. 5j  32.              gm. 

M.  S. — To  be  thoroughly  applied. 

As  in  other  forms  of  eczema,  internal  treatment  may  be  of 
value.  The  solution  of  arsenic  and  iodid  of mercury  (Donovan's 
solution),  nxii  to  v  (o.  13  to  0.3  c.c),  three  or  four  times  daily, 
is  often  of  benefit. 

Eczema  Attrium. — Eczema  of  the  ears  may  be  either  ery- 
thematous, vesicular,  or  pustular.  If  the  former,  thickening 
results,  with  desquamation  of  flakes  or  large  scales ;  if  either  of  the 
latter,  crusts  form  which  may  envelop  the  whole  ear,  the  symp- 
toms being  swelling,  redness,  and  severe  burning  and  itching 
and  if  the  process  extend  into  the  meatus,  occlusion  may  result 
causing  temporary  deafness.  The  most  characteristic  symp- 
tom of  erythematous  eczema  of  the  external  auditory  canal, 
besides  the  appearance  of  small  flakes,  is  intense  and  persistent 
itching.  It  often  results  from  the  irritation  of  a  discharge 
from  the  ear  and  from  treatment  directed  toward  the  middle 
ear. 

Treatment. — For  acute  vesicular  or  pustular  eczema,  removal 
of  the  crusts  and  the  use  of  calomel  as  an  ointment  in  the 
strength  of  30  gr.  (2  gm.)  to  the  ounce  (32  gm.)  If  chronic, 
the  use  of  tar,  as  already  suggested.  For  chronic  erythematous 
eczema  of  the  external  auditory  canal,  the  following  formula 
has  generally  controlled  this  stubborn  condition: 

I^.      Hydrargyri  flav.  oxid.  .  .  gr.  j  to  iij  0.065  to  0.2  gm. 

Morphinae  sulph gr.  j  0.065  g^^- 

Vaselini 5ij  8 .  gm. 

M.  S. — Apply  to  the  canal. 

Eczema  Genitalium.  This  is  a  most  distressing  condition. 
In  the  male,  the  scrotum  and  penis  are  involved  alone  or  to- 


TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF  ECZEMA.    75 1 

gether,  the  former  alone  being  the  more  common,  and  is  com- 
plicated with  eczema  of  the  inner  side  of  the  thigh  or  thighs. 
The  symptoms  are:  swelling,  often  edema,  moisture,  crusts,  and 
painful  fissures,  followed  by  extensive  thickening  accompanied 
with  intense  itching.  In  the  female,  the  affection  attacks  the 
labia,  and,  rarely,  the  vagina  and  mons  veneris,  and  may  ex- 
tend to  the  surrounding  parts,  especially  to  the  perineum. 
The  symptoms  of  eczema  of  the  labia  are :  great  swelling,  edema 
redness,  with  great  heat  and  a  free  discharge,  forming  crusts, 
which  are  apt  to  glue  the  apposing  surfaces  together.  If  the 
variety  be  the  erythematous,  in  place  of  a  discharge  with  crusts, 
the  symptoms  named  are  followed  by  slight  scales.  The  itch- 
ing is  most  violent  and  distressing.  Uncleanliness  and  neglect 
serve  to  aggravate  the  condition.  Glycosuria  may  be  a  factor 
in  its  production. 

Treatment. — The  parts  attacked  should  be  kept  constantly 
enveloped  in  cloths  wet  with  a  saturated  solution  of  boric  acid 
until  the  more  pronounced  inflammatory  symptoms  subside, 
-when  the  boric  acid  may  be  used  as  a  dusting  powder,  com- 
pletely enveloping  the  parts.  Mild  solutions  of  menthol  are 
valuable.  Tincture  of  myrrh  or  witch  hazel,  well  diluted,  are 
excellent  applications.  The  following  is  an  excellent  applica- 
tion for  eczema  of  the  scrotum: 

I^.     Acidi  borici q.  s.  for  sat.  sol. 

Tinct.  myrrh f5ss  16.  c.c. 

Tinct.  camphorag j  oij  60.  c.c. 

Hydrarg  chlor.  cor gr.  iij  0.2  gm. 

Aquae  destil q.s.ad  f  Bviij  q.  s.  ad  240.  c.c. 

M.  S. — Apply  several  times  daily. 

An  excellent  formula  for  eczema  of  the  vulva  is: 

I^.     Iodoform! 5ss  2 .  gm. 

Balsami  Peruvian! f  5j  4.  c.c. 

Petrolat Sj  32  .  gm. 

M.  S. — Apply  on  soft  cloths. 

Eczema  of  the  genitalia  is  always  obstinate  to  treatment  and 
requires  constant  attention  to  both  the  local  and  general  condi- 


752    TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF  ECZEMA. 

tion  of  the  patient.  Other  remedies  employed  in  eczema, 
elsewhere,  should  be  given  a  fair  trial. 

Eczema  Ani. — The  anus  may  be  attacked  alone  or  associated 
with  eczema  of  the  perineum  and  genitalia.  The  symptoms  are 
redness,  swelling,  infiltration,  and  thickening,  with  or  without 
fluid  exudation.  Fissures  of  the  anus  are  usually  present,  and 
add  to  the  distress  of  the  patient,  severe  pain  attending  each 
stool.  Parasites,  hemorrhoids,  and  rectal  discharges,  persist- 
ent itching  and  burning,  worse  after  retiring,  add  to  the  dis- 
comfort of  the  patient. 

Pruritis  ani  may  be  mistaken  for  eczema  ani.  In  the  former 
the  itching  is  only  assoc^iated  with  such  symptoms  of  inflamma- 
tion as  result  from  the  irritation  of  scratching,  while  in  the  latter 
inflammatory  symptoms  precede  the  itching. 

Treatment. — No  treatment  is  complete  without  some  means 
being  taken  to  ascertain  and  remove  the  underlying  cause.  The 
more  acute  symptoms  are  relieved  by  bathing  the  parts  with  a 
solution  of  boric  acid,  after  which  a  weak  application  of  carbolic 
acid,  either  as  a  lotion  or  ointment.  The  late  S.  D.  Gross  rec- 
ommended the  application   of  the  following: 

^.     Zinci   oxidi 5  vj  24 .  gm. 

Hydrargyri  chlor.  corrosiv.   gr.  j  0.065  g^- 

Glycerini f  5ij  8 .  c.c. 

M.  S. — Apply  thoroughly  to  affected  parts. 

Eczema  Intertrigo. — Parts  of  the  body  that  naturally  come  into 
contact  with  each  other,  as  about  the  joints,  the  inner  surfaces 
of  the  nates,  in  the  groins,  and  beneath  the  mammae,  are  fre- 
quently attacked  with  erythematous  eczema.  The  symptoms 
are  redness,  heat,  and  a  moist,  macerated  surface,  aggravated 
by  movement  of  the  affected  parts. 

Treatment. — The  application  of  a  solution  of  boric  acid,  or  the 
use  of  dusting  powders,  such  as  zinc  oleate,  starch,  or  calomel, 
is  beneficial.  It  is  essential  for  successful  treatment  that  the 
opposing  surfaces  be  separated  by  means  of  lint  or  gauze. 

Eczema  Mammarum. — The   nipples,   and    more    particularly 


TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF  ECZEMA.    753 

those  of  primiparse,  are  at  times  the  seat  of  a  vesicvdar  eczema, 
with  the  formation  of  crusts  and  fissures,  and  unless  speedily- 
relieved,  develop  eczema  rubrum.  The  pain  on  nursing  be- 
comes so  severe  that  the  mother  is  compelled  to  refuse  the  child. 
It  must  be  borne  in  mind  that  eczema  mammarum  also  occurs 
in  women  who  are  not  nursing  and  in  single  women. 
Treatment. — Tilbury  Fox  advises  the  following  plan: 
"  I.  Great  cleanliness  and  care  in  washing  away  any  remnants 
of  milk  after  each  time  the  child  is  put  to  the  breast;  and  if 
the  nipple  be  tender  and  excoriated,  use — 

"  2.  A  little  lead-water  and  calamin  powder,  as  follows: 

I^.      Liq.  plumbi f  5iss  6 .  c.c. 

Pulv.  calaminas  praep.  .  .  .  5iss  6.  gm. 

Glycerini f  5  j  4  .  c.c. 

Adipis §j  32 .  gm.         M. 

"3.  I  cover  over  the  nipple  with  a  lead  nipple-shield.  This 
excludes  the  air,  keeps  the  part  from  being  chafed,  and  I  think 
the  lead  does  good  after  the  part  has  become  less  red  and  sore. 
I  often  use  a  little  glycerite  of  tannic  acid,  painted  on  night  and 
morning. 

"  The  above  application  can  always  be  removed  with  a  little 
cold  cream  and  a  little  warm-water  sponging  before  the  child 
goes  to  the  breast." 

Eczema  Palmarum  et  Plantarum. — The  features  of  the  affec- 
tion in  both  these  regions  are  identical.  The  diagnosis  is  often 
obscured  by  the  thickened  state  of  the  epidermis.  The  symp- 
toms are  infiltration,  thickening,  callosity,  moisture  followed 
by  dryness,  and  fissuring,  the  last  named  frequently  becoming 
so  deep  and  painful  that  the  patient  is  unable  to  use  his  hands, 
or,  if  on.  the  soles,  to  walk.  The  affection  is  always  chronic, 
affecting  either  of  the  parts  alone,  or  all  at  one  and  the  same 
time.      Itching  is  a  constant  and  annoying  symptom. 

The  diagnosis  is  to  be  made  between  eczema  of  these  parts 
and   psoriasis    or    syphilis. 

Treatment. — The  plan  of  Hebra  for  eczema  rubrum  will 
48 


754   TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF  ECZEMA. 

usually  be  successful  for  this  variety.     The  following  formula  is 
also  valuable: 

I^.      Hydrargyri  oleat.  5  to  15 

per  cent 5iv  16.  gm. 

Olei  cadini f  5ss  2  .  c.c. 

Cerat.  simplicis 5iv  16 .  gm. 

M.  S. — Rub  well  into  part  morning  and  night,  first  macer- 
ating with  hot  water. 

Eczema  Unguiufn. — The  nails  are  seldom  attacked  alone,  but 
in  connection  with  eczema  manuum.  The  symptoms  are 
roughness,  want  of  polish,  unevenness,  and  a  punctate  or 
honeycomb  appearance,  similar  to  that  seen  in  psoriasis  of  the 
nails.  The  nail  becomes  depressed,  particularly  at  its  root, 
thus  interfering  with  its  nutrition,  resulting  in  loss  of  this 
appendage. 

Treatment. — Internally,  arsenic  is  a  valuable  remedy.  Lo- 
cally, the  following: 

I^.      Ung.  picis  liq 5iv  16.  gm. 

Hydrargyri  chlor.  mitis.  5ss  2.  gm. 

Vaselini 5iv  16.  gm. 

M.  S. — Apply  thoroughly. 

Eczem.a  Crurttm. — Eczema  of  the  legs  is  usually  encountered 
in  poor  persons  past  middle  age.  Varicose  veins  are  nearly 
always  present.  The  treatment  should  be  mild  and  soothing 
at  first,  including  boric-acid  lotion  or  resorcin  lotion  through 
the  day  and  a  paste  applied  as  "a  plaster.  While  the  area  is 
discharging  it  should  not  be  bandaged.  Whenever  possible, 
rest  should  be  procured.  After  the  moist  character  has  dis- 
appeared, the  diseased  area  may  be  stimulated  by  the  various 
means  already  mentioned  and  the  leg  supported  by  a  bandage, 
preferably  one  of  elastic  webbing. 

In  all  cases  of  eczema,  the  use  of  composite  remedies  of  un- 
known proportions  is  dangerous,  as  in  most  cases  the  disease  is 
aggravated.  As  previously  stated,  there  is  no  specific  for  this 
affection;  the  applications  and  dosage  varying  with  different 
individuals  and  with  different  types  of  the  disease. 


IMPETIGO    CONTAGIOSA.  755 

ECZEMA  SEBORRHOICUM. 

Seborrhoic  eczema  is  an  inflammatory  disease  beginning  pri- 
marily on  the  scalp  and  extending  to  the  face,  chest,  and  else- 
where over  the  body,  characterized  by  irregular  patches  of  red- 
ness, or  yellowish  redness  and  scaliness.  It  is  probably  due  to 
a  parasite.  The  scales  are  grayish  or  dirty-white  in  color  and 
greasy  to  the  touch.  It  resembles  seborrhea  but  has  an  addi- 
tional inflammatory  element  absent  in  that  affection. 

The  treatment  consists  in  removing  the  scales  by  means  of 
soap  and  water,  after  which  a  weak  sulphur  ointment  (gr.  xxx  to 
the  ounce)  or  resorcin  lotion  (gr.  viii  to  the  ounce)  should  be 
applied.     The  scalp  should  receive  careful  attention. 

IMPETIGO  CONTAGIOSA. 

Definition. — An  acute  contagious  inflammatory  disease 
characterized  by  the  development  of  one  or  more  discrete  super- 
ficial vesicles  or  blebs,  of  various  size  and  shape,  the  contents 
of  which  soon  become  purulent,  producing  yellowish  or  brown- 
ish crusts. 

Causes. — The  affection  is  observed  most  often  in  poor  and  un- 
clean children.  It  is  contagious  and  autoinoculable.  Occa- 
sionally it  follows  vaccination.  When  occurring  in  the  scalp,  it 
m.ay  nearly  always  be  traced  to  pediculosis  capitis.  Institu- 
tions, laundries,  barber  shops,  etc.,  often  aid  in  producing  epi- 
demics. The  exciting  cause  is  inoculation  with  the  ordinary  pus 
microorganisms. 

Pathology. — Among  the  microorganisms  capable  of  producing 
this  affection  may  be  mentioned  the  staphylococcus  aureus, 
staphylococcus  albus,  streptococcus,  and  occasionally  the  trico- 
phyton  fungus.  The  bleb  is  formed  between  the  rete  muco- 
sum  and  the  horny  layer  of  the  epidermis,  the  roof-wall  being 
afforded  by  the  latter.  A  mild  inflammatory  reaction  sur- 
rounds the  lesion  having  its  seat  in  the  upper  layer  of  the  corium. 
The  bleb  contains  a  whitish  yellow  fluid,  pus  corpuscles,  blood 
corpuscles,  epithelial  cells,  cellular  detritus,  and  microorganisms. 


756  ECTHYMA. 

Symptoms. — The  eruption  appears  with  greatest  frequency  on 
the  face  and  hands  and  often  follows  some  very  trivial  injury,  as 
a  scratch.  As  the  lesions  appear,  their  contents  are  clear,  but 
within  a  day  or  so  the  vesicle  or  bleb  character  is  lost  and  they 
assume  all  the  features  of  pustules.  The  pustules  rapidly  dry, 
forming  crusts  which  have  a  "stuck  on"  appearance.  After 
several  days  these  drop  off  leaving  a  slightly  red  area  beneath. 
Usually,  there  are  present  at  the  same  time  several  lesions  in 
various  stages  of  development.  The  vesicopustules  may  co- 
alesce forming  several  large  blebs  or  they  may  arrange  themselves 
in  half-circles.  Itching  is  very  slight  or  absent.  Neglect  or 
improper  treatment  may  cause  the  development  of  an  eczema 
on  an  impetiginous  area.  The  duration  of  the  disease  is  in 
most  instances  from  ten  days  to  two  weeks. 

Treatment. — The  crusts  should  be  removed  by  means  of  some 
nonirritating  soap  and  water,  after  which  the  following  may  be 
applied. 

I^.     Hydrarg.  ammoniat gr.  v  .3  gm. 

Hydrarg.  oxid.  rub gf-  v.  .3  gm. 

Petrolat oi  32.     gm. 

M.  S. — Apply  locally  twice  daily  (Stelwagon). 

Other  mild  antiseptics  such  as  boric  acid,  sulphur,  etc.,  may 
be  employed,  care  being  taken  to  reduce  the  strength  sufficiently 
to  avoid  irritation. 

ECTHYMA. 

Definition. — An  affection  of  the  skin,  characterized  by  the 
formation  of  one  or  more  large,  isolated,  fiat  pustules,  situated 
upon  an  inflamed  base. 

Causes. — It  is  most  common  among  those  who  live  in  squalor 
and  poverty,  in  unclean  adults,  and  in  delicate  and  poorly 
nourished  children.  Improper  and  insufficient  diet,  want  of 
ventilation,  excessive  work,  and  uncleanliness  are  all  prominent 
causes.  It  should  be  remembered  that  ecthymiform  lesions  also 
occur  at  times  in  the  course  of  pediculosis,  scabies,  and  syphilis. 


DERMATITIS   HERPETIFORMIS.  757 

Pathology. — The  lesion  is  a  typical  pustular  process,  severe 
but  superficial,  and  not  extending  beyond  the  papillary  layer 
of  the  conium.  The  pustule  is  situated  upon  a  firm  and  highly 
inflamed  base;  the  number  varies  from  one  to  a  dozen  or  more. 
With  the  disappearance  of  the  lesions  pigmentation  and  scarring 
may  follow.  The  exciting  cause  of  the  affection  is  the  presence 
of  pus-producing  microorganisms  in  the  debilitated  skin. 

Symptoms.— The  disease  is  characterized  by  the  development 
of  one  or  more  round  or  oval,  flat  pustules,  about  the  size  of  a 
pea  or  bean,  attended  with  moderate  heat,  burning,  and  pain, 
and  if  the  number  be  large,  slight  febrile  reaction.  The  pustules 
are  first  yellowish  in  color,  surrounded  by  a  firm  and  sensitive 
bright  red  areola,  the  pustule  afterward  becoming  reddish  from 
the  admixture  of  blood,  soon  drying  into  flat  crusts  of  a  brown- 
ish color.  The  duration  of  each  pustule  is  between  two  and  three 
weeks,  new  ones  forming  until  the  cause  is  removed.  The  most 
prominent  sites  are  the  thighs,  legs,  shoulders,  and  back. 

Diagnosis. — Ecthyma  may  be  distinguished  from  other 
pustular  affections  by  its  predilection  for  the  legs  of  unclean 
persons,  usually  adults,  and  by  the  presence  of  discrete,  flat, 
deep-seated    pustules    with    broad    inflammatory    areolas. 

Treatment. — Without  treatment  the  affection  may  persist 
indefinitely  but  under  proper  care  the  response  is  prompt.  A 
bath  with  a  change  of  clothing  should  begin  the  treatment. 
A  search  should  be  made  for  animal  parasites  and  if  found, 
appropiate  measures  should  be  instituted.  Nutritious  food 
and  tonics  should  be  given.  Locally,  cleanliness  and  the  fol- 
lowing application  are  of  great  value : 

I^,     Acid  carbol gr.  v  .33  gm. 

Hydrarg.  ammoniat gr.  xxx  2 ,       gm, 

Petrolat Bi  32 .       gm. 

M.  S. — Apply  locally  twice  daily, 

DERMATITIS  HERPETIFORMIS. 

Synonyms. — Duhring's   disease;   hydroa;   herpes   gestationis. 
Definition. — An    inflammatory,    superficially    seated,    multi- 
form,  herpetiform  disease,   characterized  mainly  by  erythem- 


758  PEMPHIGUS. 

atous,  vesicular,  pustular,  and  bullous  lesions,  occurring 
usually  in  varied  combinations,  accompanied  by  burning  and 
itching,  pursuing  usually  a  chronic  course,  with  a  teadency  to 
relapse  and  recur  (Duhring).  The  affection  occurs  most  often 
in  middle  life  and  arises  from  a  number  of  causes,  chief  of  which 
are  disturbances  of  the  nervous  system. 

Treatment. — The  cause  should  be  ascertained  and  removed. 
Tonics,  especially  arsenic,  act  most  favorably  on  the  disease. 
Rest,  nutritious  diet,  and  attention  to  personal  hygiene  are 
important.  Phenacetin,  acetanilid,  belladonna,  and  cannabis 
indica  will  often  relieve  the  symptoms  when  administered  in- 
ternally. Locally,  applications  containing  carbolic  acid,  resor- 
cin,  tar,  sulphur,  and  ichthyol  are  of  value.  Duhring  recom- 
mends a  strong  sulphur  ointment  in  the  vesicular  and  pustular 
types. 

PEMPHIGUS. 

Definition. — An  inflammatory  disease  of  the  skin,  either  acute 
or  chronic,  characterized  by  the  development  of  a  succession  of 
rounded,  irregularly-shaped  blebs  or  bullae,  varying  in  size 
from  a  pea  to  an  egg. 

Causes. — Obscure.  Nervous  prostration,  general  debility, 
heredity,  female  sex,  disorders  of  menstruation,  pregnancy,  etc., 
are  important  indirect  etiologic  factors. 

Pathology. — The  affection  is  considered  to  be  a  trophoneu- 
rosis. The  blebs  are  situated  in  the  epidermis  and  probably 
arise  from  a  sudden  effusion  from  the  vessels  of  the  corium  as 
the  result  of  dilatation.  The  contents  of  the  blebs  or  bullae 
are  yellowish  or  colorless  serum,  of  a  neutral  or  alkaline  reaction ; 
the  older  the  fluid,  the  more  alkaline  it  becomes.  In  the  late 
stages  of  a  bleb  the  fluid  becomes  puriform.  In  rare  instances 
blood  is  contained  in  the  bleb  {pemphigus  hcBwiorrhagicus) . 
The  papillary  vesels  are  dilated  and  the  papillae,  corium,  and  sub- 
cutaneous tissue  are  edematous  and  infiltrated  with  leukocytes. 

Symptoms. — There  are  two  varieties:  pemphigus  vulgaris; 
pemphigus  foliaceus. 


PEMPHIGUS.  759 

Pemphigus  vulgaris  may  be  acute  or  chronic  and  may  or  may 
not  be  accompanied  by  febrile  reaction.  It  is  manifested  by 
the  successive  development  of  blebs  varying  in  size  from  that  of 
a  pea  to  an  egg,  of  a  round  or  oval  shape  containing  a  colorless 
fluid,  the  color  becoming  yellowish  or  puriform  as  they  grow 
older.  They  arise  abruptly  from  the  sound  skin  with  a  definite 
line  of  demarcation,  unattended  by  symptoms  of  inflammation. 
A  characteristic  feature  of  the  eruption  is  the  successive  appear- 
ance of  the  lesions;  one  crop  no  sooner  disappears  than  another 
forms,  each  crop  running  its  course  in  from  three  to  six  or  ten 
days.  The  limbs,  face  and  trunk  are  the  regions  most  often 
affected  but  the  condition  may  also  involve  the  mucous  mem- 
branes. Itching  and  burning  of  a  mild  degree  are  present; 
occasionally    they    are    very  severe    (pemphigus  pruriginosus) . 

Pem,phigus  m.alignus  is  characterized  by  the  great  size  and 
number  of  the  blebs,  which  coalesce,  rupture,  and  are  succeeded 
by  excoriated  surfaces,  which  occasionally  take  on  ulcerative 
action,  seriously  impairing  the  patient's  health. 

Pem-phigus  foliaceus  differs  from  pemphigus  vulgaris  in  that 
the  blebs,  instead  of  being  distended  or  tense,  are  flaccid  and 
only  partially  filled  with  fluid,  and  they  rupture  before  arriv- 
ing at  their  state  of  full  development.  This  variety  also  ap- 
pears and  disappears  in  crops.  After  rupture  the  fluid  im- 
mediately dries  into  thin,  whitish  flakes,  which  are  detached 
in  quantity,  leaving  a  red,  excoriated  surface — the  rete  and 
corium.  If  the  affection  has  continued  for  some  time,  the  skin 
presents  the  appearance  of  a  superficial  scald.  The  course  of 
this  variety  is  essentially  chronic.  All  portions  of  the  body 
surface  are  liable  to  the  lesion,  as  is  also  the  mucous  membrane 
of  the  mouth  and  vagina.  It  is  most  common,  however,  upon 
the  limbs. 

Pem,phigus  vegetans  is  a  rare  variety  of  the  disease  in  which 
wart -like  vegetations  develop  upon  the  sites  of  the  ruptured 
blebs. 

Diagnosis. — The  disease  is  rare,  and  the  presence  of  blebs  in 
any  given  case  should  direct  the*  attention  to  pemphigus  only 
after     bullous     erythema     multiforme,     impetigo     contagiosa, 


760  POMPHOLYX. 

bullous  syphiloderm,  and  bullous  eruptions  of  artificial  produc- 
tion have  been  excluded.  The  characteristics  of  pemphigus 
are  its  chronicity,  and  the  appearance  in  crops  of  large,  tense, 
abruptly  elevated  non-inffammatory  blebs. 

Prognosis. — The  outlook  is  uncertain.  Most  cases  pursue  a 
very  chronic  course  ultimately  ending  in  death  from  some 
intercurrent  disease.  Mild  attacks  are  less  liable  to  persist  and 
often  end  in  recovery.  Constitutional  disturbances,  extensive 
involvement  of  the  skin,  and  the  presence  of  flaccid  or  hemor- 
rhagic blebs  are  unfavorable  signs. 

Treatment. — The  general  health  should  be  restored  and  main- 
tained by  rest,  nutritious  food,  and  the  administration  of  tonics 
especially  arsenic  and  quinin.  Locally,  the  blebs  should  be 
punctured  as  soon  as  formed  and  dusting  powders  such  as  boric 
acid,  zinc  oxid,  or  starch  should,  be  applied  locally.  Sedative 
lotions  are  also  valuable.      Hebra  advises  the  continuous  bath. 

POMPHOLYX. 

Synonyms. — Dysidrosis ;  cheiro-pompholyx. 

Definition.  An  acute  inflammatory  disease  of  the  skin, 
affecting  especially  the  hands  and  feet,  characterized  by  the 
appearance  of  vesicular,  vesicobuUous,  and  bullous  lesions,  at- 
tended by  burning,  tingling,  or  itching. 

Causes. — It  occurs  in  adults  of  both  sexes,  and  is  believed  to 
depend  upon  some  general  disturbance  of  the  nervous  system. 
Mental  overwork  and  lowered  nerve-tone  are  ascribed  as 
causes.     The  disease  is  considered  to  be  a  vasomotor  neurosis. 

Symptoms. — The  lesions  are  distributed  symmetrically,  and 
occur  as  deep-seated  tense  vesicles  usually  on  the  lateral  and 
palmar  aspects  of  the  hands,  fingers,  feet,  and  toes,  accompanied 
by  itching  and  burning.  They  may  coalesce,  but  more  fre- 
quently they  remain  discrete,  showing  no  tendency  to  rupture. 
The  contents  are  absorbed  and  desquamation  follows.  The 
duration  of  the  attack  is  from  several  days  to  a  few  weeks. 
Recurrence  is  common.  ^ 

Diagnosis. — The    affection    may    resemble    vesicular   eczema 


HERPES   SIMPLEX.  76 1 


ariLi 


dermatitis  venenata.  The  distinctive  features  of  pom- 
pholyx  are  the  location,  the  tense,  deep-seated  character  of  the 
vesicles  which  do  not  tend  to  rupture,  the  subjective  symptoms, 
the  absence  of  acute  inflammation,  and  the  tendency  to  recur. 

Prognosis. — The  acute  attacks  seldom  last  more  than  one  or 
two  weeks  and  the  course  is  seldom  influenced  by  treatment. 
The  tendency  to  relapse  has  already  been  mentioned. 

Treatment. — Recurrence  may  be  prevented  to  a  great  extent 
by  the  employment  of  measures  calculated  to  improve  the 
general  health.  Locally,  pastes,  ointments,  or  lotions  con- 
taining antipruritic  drugs  often  allay  the  subjective  symptoms. 

HERPES  SIMPLEX. 

Synonyms. — Fever  blisters;  "cold  sore." 

Definition. — An  acute  inflammation  of  the  skin,  character- 
ized by  the  development  of  one  or  more  groups  of  vesicles, 
filled  with  a  clear  serum,  occurring  for  the  most  part  about  the 
face    {herpes  facialis)    and    genitalia    {herpes   pro  genitalis). 

Causes. — Herpes  facialis  occurs  during  the  course  of  febrile 
and  nervous  disorders  and  is  often  associated  with  gastrointes- 
tinal disorders.  Herpes  progenitalis  usually  arises  from  un- 
cleanliness  and  friction. 

Pathology. — The  affection  is  neurotic  in  origin,  and  by  some 
observers  is  believed  to  be  due  to  a  toxic  neuritis  of  a  cutaneous 
nerve. 

Symptoms. — The  appearance  of  the  vesicles  is  usually  pre- 
ceded by  a  feeling  of  heat  in  the  region,  together  with  slight 
tum.ef action  or  swelHng.  Rarely  the  herpetic  attack  is  attended 
with  malaise  and  pyrexia.  The  eruption  usually  appears  in 
the  form  of  a  small  cluster  of  pin-head  to  split -pea  sized  vesicles, 
containing  a  clear  fluid,  becoming  cloudy,  afterward  puriform 
and  drying  in  small  yellowish  or  brownish  crusts;  they  are  few 
in  number,  and  may  coalesce.  They  disappear  without  leaving 
a  scar. 

Herpes  facialis  occurs  upon  any  portion  of  the  face,  but  most 
frequently  about  the  \\^s,— herpes  lahialis.  The  alse  of  the  nose, 
auricles,  and  the  mucous  membranes  of  the  mouth  and  tongue 


762  LICHEN   PLANUS. 

are  frequent  locations,  in  the  latter  appearing  as  excoriated 
patches  from  rupture  of  the  vesicles. 

Herpes  progenitalis ;  in  the  male  the  chief  site  is  the  prepuce 
{herpes  prceputialis) .  In  the  female  they  are  comparatively  rare ; 
but  when  occurring  they  appear  upon  the  labia  majora  and  mi- 
nora and  the  skin  about  the  vulva.  This  variety  is  preceded  by 
burning,  itching,  or  neuralgic  pains,  and  is  accompanied  by  red- 
ness, congestion,  and  more  or  less  edema.  The  importance  of 
this  condition  resides  in  the  fact  that  not  only  may  it  be  readily 
mistaken  for  some  venereal  disease  but  it  may  also  afford  a  site 
for  inoculation  for  some  more  serious  affection. 

Herpes  gestationis ;  a  rare  affection  of  the  skin  occurring  dur- 
ing pregnancy,  consisting  of  erythema,  papules,  vesicles,  and 
bullce,  attended  by  intense  burning  and  itching.  It  may  ap- 
pear at  any  time  of  pregnancy  up  to  the  seventh  month,  and 
continues  until  after  delivery.  It  is  a  variety  of  dermatitis 
herpetiformis  {q.  v.). 

For  herpes  zoster  see  page  666. 

Treatment. — Ordinary  herpes  of  the  face  seldom  requires 
treatment,  the  lesions  drying  and  falling  off  usually  within  a 
week  or  ten  days.  The  application  of  dusting  powders,  cold 
cream,  or  boric  acid  solution  often  aids  in  lessening  the  itching 
and  preventing  infection. 

In  herpes  progenitalis,  cleanliness  is  of  first  importance.  The 
lesions  should  be  carefully  washed  with  boric-acid  solution  and 
then  dusted  with  calomel,  aristol,  or  similar  powders.  The 
parts  may  be  rendered  less  sensitive  in  frequently  recurring 
cases  by  astringent  lotions  containing  tannic  acid  or  zinc  sul- 
phate. Circumcision  will  be  necessary  when  an  unusually  long 
prepuce  is  the  cause  of  the  condition.  In  recurring  cases  of 
herpes  of  the  vulva,  arsenic,  internally,  is  of  benefit. 

LICHEN  PLANUS. 

Lichen  planus  is  a  chronic  inflammatory  disease  of  the  skin 
characterized  by  small,  flat,  angular,  umbilicated,  glazed,  red- 
dish papules,  accompanied  by  intense  itching.  The  eruption 
may  appear  suddenly  or  gradually  and  usually  appears  on  the 


LICHEN   PLANUS.  763 

extremities.  The  lesions  vary  in  size  from  a  pin-head  to  a  pea 
and  tend  to  occur  in  patches  which  often  assume  a  linear  form. 
The  papules  are  fiat,  angular,  glazed,  slightly  umbilicated  and 
of  a  reddish  or  violaceous  color.  As  the  affection  progresses 
scales  form  on  the  lesions.  Itching  is  marked.  After  the 
eruption  subsides,  the  sites  of  the  lesions  remain  pigmented  for 
an  indefinite  period. 

Causes. — Unknown.  Disturbances  of  the  nervous  system, 
such  as  result  from  prolonged  mental  strain,  overwork,  etc.,  are 
prominent  factors  in  the  etiology.  The  condition  is  observed 
with  greatest  frequency  in  middle-aged  individuals  in  whorA 
there  is  marked  disturbance  of  the  general  health. 

Pathology. — The  lesions  are  induced  by  some  neurotic  dis- 
turbance as  yet  not  well  understood.  They  are  situated  in  the 
upper  part  of  the  corium  usually  surrounding  the  sweat-ducts. 
The  earliest  step  in  their  production  is  probably  a  neuroparalytic 
hyperemia,  after  which  there  is  a  circumscribed  round-cell  in- 
filtration of  the  corium  with  enlargement  of  the  papillae  and  pro- 
liferation of  the  cells  of  the  rete. 

Diagnosis. — The  distinctive  features  of  lichen  planus  are  its 
chronicity  and  the  shape,  size,  and  color  of  the  lesions. 

Prognosis. — The  course  is  essentially  chronic,  but  proper 
treatment  often  causes  disappearance  of  the  eruption. 

Treatment. — Internally;  remedies  such  as  arsenic,  iron,  quinin, 
strychnin,  and  cod-liver  oil  should  be  administered.  Rest  is  of 
value.  The  diet  should  be  regulated  and  the  personal  hygiene 
should  receive  attention. 

Locally,  lotions  and  ointments  containing  antipruritics  should 
be  employed.  Tar,  mercury,  salicylic  acid,  menthol,  and  car- 
bolic acid  are  useful  in  this  connection. 

Lichen  ruber  acuminatus  is  characterized  by  the  appearance 
of  discrete  millet-sized,  acuminate,  scaly  papules.  The  trunk  is 
the  most  common  situation.  The  lesions  are  scattered  and  show 
no  tendency  to  grouping.  They  are  localized  in  the  hair-follicles. 
The  hair-sheaths  are  changed  to  funnel-shaped  formations,  with 
the  wide  end  external  and  the  narrow  end  pointed  toward  the 
bulb,  and  the  papillae  and  contained  blood-vessels  are  enlarged. 


764  PRURIGO. 

Itching  is  not  marked.  The  affection  is  very  chronic  and  is 
attended  by  constitutional  disturbances.  If  left  to  itself,  the 
disease  ultimately  terminates  fatally.  The  treatment  is  similar 
to  that  of  lichen  planus  but  is  seldom  of  much  benefit. 

Lichen  Scrofulosus. — A  chronic  disease  of  the  skin,  char- 
acterized by  the  formation  of  millet-seed  sized,  rounded  or  flat- 
tened, pale  red  or  salmon  colored,  more  or  less  grouped,  scaly 
papules.  They  are  observed  most  frequently  on  the  trunk  in 
scrofulous  individuals  and  are  unaccompanied  by  itching.  The 
treatment  consists  largely  in  the  internal  use  of  cod-liver  oil, 
^on,  quinin,  and  strychnin.  The  cod-liver  oil  may  also  be 
employed  locally. 

PRURIGO. 

Prurigo  is  a  rare  chronic  inflammatory  disease,  occurring  first 
in  early  childhood  and  lasting  indefinitely,  characterized  by  pin- 
head  to  lentil-seed  sized,  pale,  red  papules  appearing  usually 
on  the  extensor  surfaces  of  the  extremities  and  accompanied  by 
intense  itching.  The  cause  is  unknown.  The  affection  occurs 
most  often  among  the  poor.     The  outlook  is  unfavorable 

Treatment. — Every  effort  should  be  made  to  improve  the 
general  health  and  to  this  end  the  diet  and  hygiene  should 
receive  attention.  Cod-liver  oil,  iron,  manganese,  hypophos- 
phites,  etc.,  should  be  given.  Locally,  bathing  in  plain  water  or 
medicated  solutions,  betanaphthol  ointment  (2  per  cent,  in 
children,  5  per  cent,  in  adults),  sulphur  ointment  5i  to  the 
ounce),  and  tar  preparations  are  of  great  value. 

ACNE. 

Synonym. — Acne  vulgaris. 

Definition. — An  inflammation,  usually  chronic,  of  the  seba- 
ceous glands,  characterized  by  the  development  of  papules,  tuber- 
cles, or  pustules,  or  by  a  combination  of  such  lesions,  usually  in 
various  stages  of  formation,  occurring  for  the  most  part  upon  the 
face. 

Varieties. — Acne  papulosa;  acne  pustulosa;  acne  artificialis. 

Causes. — The  exciting  cause  is  not  well  understood;  by  many 


ACNE.  765 

observers  it  is  believed  to  be  a  microorganism.  As  predisposing 
causes  may  be  mentioned  puberty,  digestive  disturbances,  con- 
stipation, menstrual  irregularities,  anemia,  chlorosis,  circulatory 
disturbances,  sedentary  life,  general  debility,  and  lack  of  muscu- 
lar tone.  The  presence  of  dust  and  oil  on  the  face,  uncleanli- 
ness,  contact  with  tar,  and  the  internal  administration  of  the 
bromids  and  iodids  in  excess  are  also  etiologic  factors.  Acne 
may  exist  alone  or  be  associated  with  comedo  or  seborrhea. 

Pathology. — An  inflammation  of  the  sebaceous  gland  structure 
and  surrounding  tissues.  There  first  occurs  retention  of  the 
sebaceous  secretion,  which  is  soon  followed  by  hyperemia  and 
exudation  about  the  glands  and  in  the  gland-wall  {acne  papu- 
losa), and  infiltration  of  the  connective  tissue  {acne  tubercula), 
followed  by  suppuration  {acne  pustulosa) .  If  the  inflammatory 
action  be  severe,  destruction  of  the  gland  with  a  resulting  cica- 
trix occurs. 

Syinptom.s. — Acne  papulosa  or  acne  punctata.  This  variety  is 
the  earliest  stage  of  the  inflammatory  action,  and  is  of  short 
duration,  soon  followed  by  the  development  of  pus.  It  is  char- 
acterized by  the  occurrence  of  pin-head  to  pea-sized,  fiat,  more  or 
less  pointed  papules,  situated- about  the  sebaceous  follicles,  light 
in  color,  with  a  minute  central  black  point,  the  opening  of  the 
sebaceous  duct  {acne  punctata).  Pustules  are  not  infrequently 
observed  scattered  among  the  papules.  The  lesion  is  unaccom- 
panied with  either  local  or  constitutional  symptoms.  While 
the  forehead  is  the  most  frequent  seat  for  this  variety,  they 
sometimes  are  seen  elsewhere. 

Acne  Pustulosa. — This  is  the  fully  developed  affection.  It  is 
seen  upon  the  face,  neck,  shoulders,  and  back  as  pin-head  to 
pea-sized,  rounded  or  acuminated  pustules,  seated  upon  an  in- 
filtrated, reddish  base  of  superficial  or  deep  inflammatory  prod- 
uct {acne  indurata).  Scattered  among  the  pustules  may  be 
seen  numerous  papules.  There  are  no  constitutional  symptoms, 
nor  is  pain  present  unless  the  pustule  be  handled. 

Acne  cachecticorum  is  that  variety  observed  on  the  trunk  and 
extremities  of  cachectic  individuals.  The  lesions  are  large  and 
indolent , 


766  ACNE. 

Acne  atrophica  is  characterized  by  the  formation  of  small 
atrophic  scars  on  the  disappearance  of  the  lesions,  while  in  acne 
hypertrophic  a,  the  scar-tissue  is  hypertrophic. 

Acne  artificialis  is  rather  a  clinical  variety,  the  result,  usually, 
of  large  doses  of  the  bromids  or  iodids,  the  lesion  being  identi- 
cal with  that  of  acne  pustulosa. 

Diagnosis. — The  characteristics  of  the  disease  are  the  course, 
location,  and  lesions  situated  at  the  sites  of  the  sebaceous  glands. 

Prognosis. — The  affection  is  essentially  chronic,  lasting  for  a 
number  of  years.  With  persistent  treatment  recovery  is  rather 
common,. 

Treatment. — Before  prescribing  for  any  case  of  the  disease,  it 
should  be  carefully  studied  as  to  its  etiology,  since  this  bears 
directly  upon  the  treatment.  In  most  instances,  the  digestive 
tract  is  the  subject  of  various  disturbances  and  internal  medica- 
tion is  consequently  indicated.  The  character  of  the  food  should 
be  regulated,  being  careful  to  eliminate  all  substances  known  to 
be  difficult  of  digestion  in  the  particular  case  under  observation, 
and  especially  pastries,  gravies,  cheese,  fried  foods,  pork,  etc., 
from  the  diet.  Alcoholic  beverages  should  be  interdicted  and 
tea  and  coffee  allowed  in  very  moderate  quantities.  Constipa- 
tion is  common  and  requires  for  its  relief  rnoderate  exercise, 
abdominal  massage,  and  laxatives  in  addition  to  regulation  of 
the  diet.  Among  the  laxatives  of  value  in  this  connection  may 
be  mentioned  the  compound  rhubarb  pill,  the  aloin,  strychnin, 
and  belladonna  pill,  calomel,  blue  mass,  cascara  sagrada,  and 
the  salines.  The  saline  waters  such  as  Hunyadi  Janos,  Saratoga 
and  Friedrichshall  are  very  beneficial.  The  administration  of 
sodium  hypophosphite,  gr.  x  (0.6  gm.),  in  solution  three  times 
daily  after  meals  is  also  of  value. 
Stelwagon  employs  the  following  combination : 

I^.     Sodii  benzoat 5ss  to  ii    2  .  to     8  .  gm. 

Tr.  nucis  vomicae f  5ii  8  .  c.c. 

Fluidextract.  cascarae  ...    f  5ii  to  iv  8  .  to  16  .  c.c. 
Tr.  cardamom,  comp. 

q.  s.  ad  f  5iii  90.  c.c. 

M.  S. — Teaspoonful  three  times  daily  in  water  after  meals. 


ACNE.  767 

The  following  mixture  known  as  "mistura  ferri  acida"  is  ex- 
tensively used  with  success  in  cases  complicated  with  constipa- 
tion and  anemia: 

I^.      Magnesii  sulphat. Bi  32 .  gm. 

Ferri  sulphat gr.  iv  to  viii     o  .  2  5  to  o  .  5  gm. 

Acid  sulphuric,  dilut.  ..  .    foitoii  4.       to     .8c.c. 

Aq.  menth.  pip..q.  s.  ad  fSiv  120.  c.c. 

M.  S. — Tablespoonful  in   water   half   an   hour   before  break- 
fast. 

In  cases  in  which  chlorosis  or  anemia  exists,  tonics  such  as 
iron,  arsenic,  and  manganese  should  be  employed.  The  citrate 
of  iron  and  quinin  in  combination  with  glycerin  is  an  excellent 
preparation  for  these  cases.  In  cachetic  or  scrofulous  individ- 
uals cod-liver  oil,  syrup  of  the  iodid  of  iron,  syrup  of  the  hypo- 
phosphites,  and  similar  remedies  should  be  administered.  The 
bichlorid  of  mercury,  gr.  i/ioo  to  1/60  (0.00065  "to  o.ooii  gm.), 
three  times  daily,  is  of  great  value  as  a  tonic  in  many  cases.  In 
pustular  cases,  calcium  sulphid,  gr.  i/io  to  1/2  (0.0065  "to  0.032 
gm.),  three  times  daily,  is  reputed  to  be  of  benefit.  Change  of 
occupation  frequently  aids  the  treatment  materially.  Uterine 
disorders  should  always  receive  attention,  as  they  often  influ- 
ence the  condition  considerably.  Other  genital  conditions  act- 
ing reflexly  should  not  be  neglected.  In  young  adult  males,  the 
passage  of  a  fair-sized  steel  sound  has  been  advocated. 

Local  Treatment. — The  objects  of  the  local  treatment  are  to 
stimulate  the  sebaceous  glands  to  healthy  activity  and  to  re- 
move existing  lesions.  A  form  of  treatment  that  has  been 
followed  by  success  in  many  cases  consists  in  first  washing  the 
face  every  night  with  very  hot  water;  after  the  face  has  partly 
dried  precipitated  sulphur  is  dusted  on  with  a  powder  puff-ball, 
and  removed  in  the  morning  by  means  of  hot  water  and  the  face 
lightly  mopped  dry. 

Hyde  recommends  evacuating  the  contents  of  the  lesions  by 
means  of  a  needle,  rather  encouraging  slight  bleeding,  after 
which  the  parts  are  to  be  bathed  with  hot  water  and  while  the 
parts  are  still  wet  thoroughly  scrubbed  with  green  soap,  cleansed 


768  ACNE. 

with  water,  dried,  and  anointed  with  sulphur  ointment.  This 
treatment  is  very  stimulating  and  is  applicable  only  to  deep- 
seated,  indolent  lesions.  Sometimes  the  affected  areas  are  de- 
cidedly irritated  when  first  seen  or  become  so  from  treatment. 
Under  such  circumstances,  a  saturated  solution  of  boric  acid  in 
alcohol  or  water,  or  calamin  lotion,  should  be  used. 

Usually,  when  the  lesions  are  seated  very  superficially  the 
following  "lotio  alba"  will  be  of  benefit: 

I^.      Zinc,  sulphat. 

Potassium  sulphur et ..  aa  gr.  xxx  2.  gm. 

Aquae  rosse f5iv  120.  c.c. 

M.   S. — Apply  locally  at  night,   washing  ofT  the  sediment 
with  water  in  the  morning. 

In  the  preparation  of  this  solution,  each  ingredient  should  be 
dissolved  separately  and  then  mixed.  When  completed  there 
should  be  a  white  precipitate.  The  addition  of  glycerin  (nxx  to 
the  ounce)  will  cause  the  sediment  to  be  held  in  suspension  and 
often  aids  in  the  efficiency  of  the  application.  Other  prepara- 
tions of  sulphur  such  as  sulphur  ointment  and  paste  (3i  to  the 
ounce),  and  Kummerfeld's  solution  are  also  of  value. 

I^.      Sulph.  precip 5iv  15.5  gm. 

Pulv.  camphorse gr.  x  0.6  gm. 

Pulv.  tragacanth gr.  xx  i .  2  gm. 

Aquae  rosae, 

Liq.  calcis aa  f  Bii  aa  60.0  c.c. 

M.    S. — Kummerfeld's  solution.     Apply  locally  night  and 
morning. 

Duhring  recommends  the  use  of  the  following,  after  washing 
the  parts  with  hot  water: 

I^.     Sulphuris  prascip oj  .4.     gm. 

Glycerini f  oss  2  .     c.c. 

Adipis  benzoat 5j  32.     gm. 

01.  ros^ rr^iij  o  .  2  c.c. 

M.  Ft.  unguentum. 

S. — To  be  thoroughly  rubbed  into  the  skin  at  night. 


ACNE   ROSACEA.  769 

The  following  is  employed  extensively  in  sluggish  cases: 

I^.     Sulph.  precip oi  4 .  gm. 

-^theris f  oiv  16  .  c.c. 

Alcohol q.  s.  ad  f  5iv  120.  c.c. 

M.  S. — Apply  locally  twice  daily. 

Resorcin  is  often  used  in  the  form  of  an  ointment  (oi  to  the 
ounce).  Among  other  local  remedies  may  be  mentioned  ich- 
thyol,  mercurial  preparations,  betanaphthol,  and  salicylic  acid. 
Incision,  expression,  faradism,  massage,  and  the  x-ray  are  also 
beneficial  in  selected  cases. 

Bartholow  used  the  following  method  in  cases  of  indurated 
acne,  with  success:  The  sebaceous  matter  was  first  dissolved 
out  with — 

I^.     Liquor  potassae foj  4.  c.c. 

Aquse  destil foj  30.  c.c. 

M.  S. — Apply  only  to  the  acne  lesions,  after  which  the  fol- 
lowing ointment  should  be  used: 

I^.     Plumbi  nitrat gr.  xv  i .  gm. 

Petrolat Bj  32  .  gm. 

M.  S. — Apply  locally  twice  daily. 

ACNE  ROSACEA. 

Definition. — A  chronic  hyperemia  or  inflammatory  affection 
of  the  nose  and  cheeks,  characterized  by  redness,  hypertrophy 
of  the  skin,  and  dilatation  and  enlargement  of  the  blood-vessels 
supplying  the  part,  with  the  development  of  more  or  less  acne. 

Causes. — The  etiology  is  often  obscure.  Gastrointestinal  dis- 
orders, anemia,  exposure  to  heat  and  cold,  uterine  disease, 
puberty,  menopause,  general  debility,  seborrhea,  nasal  disease ; 
and  the  excessive  indulgence  in  tea,  coffee,  and  alcohol  are  the 
most  common  causes.  Continual  ingestion  of  proprietary 
medicines  often  induces  it.  Both  sexes  may  be  attacked.  The 
affection  usually  occurs  in  middle  life. 

Pathology. — There  first  occurs  blood  stasis  in  the  vessels  of  the 
part,  producing  the  undue  redness.     As  a  result  of  the  stasis, 

49 


770  ACNE   ROSACEA. 

sooner  or  later  the  capillaries  are  dilated  and  hypertrophied, 
and  following  the  interrupted  circulation,  inflammation  of  the 
sebaceous  gland  (acne)  occurs,  with  the  development  of  papules 
and  pustules.  This  constitutes  the  typical  acne  rosacea.  The 
affection  may  proceed  no  further,  remaining  at  this  point  for 
years,  or,  rarely,  the  pathology  of  this  stage  is  exaggerated,  the 
involved  tissues  all  hypertrophying,  and  the  connective  tissue 
undergoing  a  true  hyperplasia,  causing  increased  size  and  ab- 
normal shape  of  the  nose. 

Symptoms. — The  onset  of  the  affection  is  slow  and  insidious, 
characterized  at  first  by  more  or  less  diffused  redness  of  the  part, 
the  color  being  aggravated  by  contact  with  water  or  cold  air.  If 
the  nose  be  the  part  attacked,  it  is  usually  greasy  (seborrhoeic) , 
and  is  apt  to  be  cool  or  even  cold.  This  condition  may  remain 
for  years,  but  sooner  or  later  the  evidence  of  dilatation  and  hyper- 
trophy of  the  capillaries  is  apparent  by  the  more  decided  and 
permanent  redness,  and  upon  close  examination  the  enlarged 
cutaneous  blood-vessels  are  seen  as  delicate  or  coarse  red  lines, 
running  superficially  over  the  skin  in  an  irregular  and  tortuous 
course.  Shortly  afterward  there  are  developed  upon  the  hyper- 
emic  and  hypertrophied  skin,  papules  (acne  papulosa)  and 
pustules  (acne  pustulosa),  their  number  never,  however,  being 
very  great.  This  constitutes  true  acne  rosacea.  The  disease 
may  remain  in  this  state,  or,  rarely,  the  cutaneous  tissue  be- 
come greatly  hypertrophied,  the  blood-vessels  enormously 
dilated,  the  glands  enlarged,  and  the  connective  tissue  under- 
goes hyperplasia,  resulting  in  permanent,  dark-red,  bulky  for- 
mations, the  shape  of  the  nose  being  contorted  into  various 
irregular  forms  {rhino phy ma) . 

Diagnosis. — The  affection  may  usually  be  distinguished  from 
other  affections  by  the  dilatation  of  the  blood  vessels,  the  acne, 
papules,  pustules,  and  tubercles,  and  the  tendency  to  over- 
growth of  the  connective  tissue.  The  course  is  chronic  and 
ulceration  never  occurs. 

Prognosis. — In  the  early  stages,  considerable  benefit  may  be 
afforded  by  appropriate  treatment.  Persistence  of  the  milder 
forms  of  the  disease  can  usually  be  traced  to  a  disinclination  on 


ACNE    ROSACEA.  77  I 

the  part  of  the  patient  to  carry  out  the  treatment.  In  the 
occurrence  of  connective-tissue  hypertrophy,  the  prognosis  as 
to  cure  becomes  less  favorable. 

Treatment. — As  in  simple  acne,  a  great  portion  of  the 
treatment  should  be  directed  toward  the  digestive  tract. 
Tea,  coffee,  and  alcohol  should  be  positively  prohibited.  The 
remedies  advised  in  acne  vulgaris  are  also  applicable  in  this 
condition.  Extract  of  thyroid  gland,  gr.  i  to  ii  (0.065  to  0.13  gm.), 
three  times  daily,  over  a  long  period  has  been  of  benefit. 

Locally,  sulphur  preparations,  particularly  lotio  alba  and 
Kummerfeld's  lotion,  are  especially  valuable.  Resorcin  lotion, 
gr.  V  to  X  (0.35  to  0.6  gm.),  to  the  ounce,  is  of  benefit  in  some 
cases.     The  following  may  be  used: 

I^.      Hydrargyri  chlor.corrosiv.   gr.  ij  0-i3  gm- 

Petrolat 5j  32 .        gm. 

M.  S. — Apply  thoroughly. 

Or  the  following  suggested  by  G.  H.  Fox: 

I^.      Chrysarobini oss  2 .        gm. 

Collodii f  5  j  30 .         c.c. 

M.    S. — Put   a  brush   through  the   cork   and   paint  lesions 
every  evening. 

For  the  second  stage  stronger  applications  are  usually  re- 
quired. The  dilated  capillaries  should  be  incised  with  a  sharp 
knife,  in  the  hope  that  adhesive  inflammation  may  close  the 
caliber  of  the  vessels,  cold  water  compresses  being  used  to  con- 
trol the  bleeding,  a  few  of  the  dilated  vessels  being  thus  treated 
every  day  or  two,  until  all  have  been  incised.  Another  plan  is 
to  paint  the  affected  parts  once  or  twice  a  week  with  a  10  to  20 
gr.  solution  of  potassium,  following  its  application  with  an 
emollient  poultice.  Electrolysis  has  also  been  recommended. 
Vleminckx's  solution  may  be  employed  in  some  cases: 

I^.      Calais 5 ss  16.  gm. 

•  Sulph.  precip Si  32  .  gm. 

Aquas f§x  310.  c.c. 

M.      Boil  to  6  ounces  and  filter. 

S. — Add   I   part  of  the  solution  to   10  parts  of  water  and 
apply  locally. 


772  SYCOSIS    VULGARIS. 

SYCOSIS  VULGARIS. 

Definition. — A  chronic  inflammatory  disease  of  the  bearded 
region,  due  to  invasion  of  the  hair-follicles  by  pus-producing 
microorganisms,  characterized  by  papules,  pustules,  and 
tubercles. 

Causes. — The  affection  usually  occurs  on  the  upper  lip,  and  is 
often  secondary  to  nasal  discharge.  The  exciting  cause  is  some 
form  of  staphylococcus. 

Pathology. — The  disease  consists  of  an  inflammation  within 
and  around  the  follicles  as  is  shown  by  the  presence  of  hair  in 
each   of  the  lesions. 

Symptoms. — The  manifestations  consist  of  pea-sized  papules 
and  pustules,  each  perforated  by  a  hair.  The  interfollicular 
spaces  are  free  from  involvement  by  these  lesions  but  may  be 
swollen  and  infiltrated.  The  lesions  dry,  forming  crusts,  and 
are  attended  by  itching,  burning,  and  slight  pain.  The  hairs 
remain  firmly  attached  except  in  the  occurrence  of  marked 
suppuration.  The  upper  lip  is  the  most  common  seat  but  other 
portions  of  the  beard  may  be  attacked.  The  affection  is  very 
chronic. 

Diagnosis. — Care  should  be  taken  not  to  confuse  sycosis  vul- 
garis with  tinea  sycosis  or  ringworm  of  the  beard.  In  the 
former,  there  are  discrete  papules  and  pustules  at  the  sites  of  the 
follicles;  the  hairs  are  firmly  attached,  as  a  rule;  the  course  is 
chronic;  the  upper  lip  is  most  often  involved;  and  there  is  no 
fungus  demonstrable. 

Pustular  eczema  may  be  distinguished  from  sycosis  by  its 
more  general  distribution  (not  limited  to  the  follicles),  its  oozing 
character,  and  its  diffuse  inflammatory  base. 

Prognosis. — The  disease  is  very  chronic  and  recurrences  are 
common.  Persistence  in  the  treatment  is  usually  attended  by 
great  benefit. 

Treatment. — Local  applications  are  of  greatest  value.  The 
hairs  should  be  kept  very  short  either  by  clipping  or  shaving. 
When  there  is  marked  suppuration  the  affected  hairs  should  be 
extracted  by  forceps.      If  the  surface  is  acutely  inflammatory  a 


PSORIASIS.  773 

saturated  solution  of  borid  acid,  zinc  oxid  ointment,  or  other 
sedative  preparation  should  be  applied.  Usually,  sulphur 
ointment  (5i  to  the  ounce)  is  of  most  value.  It  should  be 
rubbed  in  freely  night  and  morning.  Ammoniated  mercur^, 
ichthyol,  and  bichlorid  of  mercury  are  also  useful  at  times. 

Lupoid  sycosis  is  a  rare  form  of  the  disease  which  terminates 
in  scarring  and  atrophy  of  the  hair-follicles.  It  is  essentially 
chronic  and  vSeldom  responds  to  treatment. 


PSORIASIS. 

Synonym. — Lepra  (used  by  early  writers). 

Definition. — A  chronic  affection  of  the  skin,  characterized  by 
reddish,  more  or  less  thickened  and  elevated,  dry,  inflammatory, 
and  somewhat  wrinkled  patches,  variable  as  to  size,  shape,  and 
number,  and  covered  with  abundant  whitish  or  grayish  colored, 
imbricated  scales. 

Cause. — Not  known.  The  source  of  the  affection  is  probably 
limited  to  the  skin  itself.  Gout,  rheumatism,  heredity,  and 
parasitic  infection  are  believed  to  be  causal  factors.  It  occurs 
in  the  robust  and  in  the  feeble,  and  in  both  males  and  females. 
It  usually  appears  in  early  life,  and  recurs  at  intervals  for  years. 
It  is  not  contagious. 

Pathology. — "The  disease  is  essentially  a  hyperplasia  of  the 
normal  constituents  of  the  Malpighian  layer  (mucous  layer). 
The  increase  takes  place  chiefly  in  the  interpapillary  portion  of 
the  layer,  the  growth  of  which  downward  causes  an  apparent  in- 
crease in  size  of  the  papillae  of  the  corium,  which,  however,  on 
closer  examination,  are  found  not  to  be  enlarged.  In  the  later 
stages  of  the  disease  the  more  superficial  blood-vessels  of  the 
corium  become  dilated,  a  more  or  less  considerable  emigration  of 
the  white  blood  corpuscles  takes  place,  and  the  immediate  neigh- 
borhood of  the  vessels,  together  with  the  connective  tissue  of  the 
corium,  becomes  the  seat  of  a  round-cell  infiltration,  which,  with 
the  effusion  of  serum,  separates  the  connective-tissue  bundles 
and   fibers  into  an  open  meshwork.     During  the  period  of  dis- 


774  PSORIASIS. 

appearance  of  the  disease  there  is  a  gradual  return  to  the 
normal  condition,  until  the  hyperplasia,  dilatation  of  the  blood- 
vessels, and  cell  infiltration  has  completely  disappeared.  The 
hair  in  psoriasis  is  affected  from  the  beginning  of  the  disease, 
hyperplasia  of  the  external  root-sheath,  the  structure  correspond- 
ing to  the  Malpighian  layer  of  the  epidermis,  taking  place,  with 
extension  of  the  hyperplastic  structure,  into  the  surrounding 
cutis.  The  sebaceous  and  sweat-glands  are  not  at  any  time 
affected"  (Robinson). 

Symptoms. — Psoriasis  begins  as  small,  reddish  spots  of  the 
size  of  a  pin's  head,  which  immediately  become  covered  with 
scanty  or  abundant  whitish  or  grayish  imbricated  scales.  The 
spots  gradually  increase  in  diameter  by  peripheral  extension, 
forming  patches  of  various  sizes  and  shapes. 

If  an  attempt  be  made  to  detach  one  of  the  scales  by  means 
of  the  finger-nail,  it  will  be  found  to  adhere  quite  firmly  to  the 
skin,  and  to  be  about  the  thickness  of  a  card- board.  If  the 
reddish  patch  thus  made  bare  be  pinched  up  between  the  finger 
and  thumb,  and  compared  with  a  similar  pinch  of  the  healthy 
skin,  its  inflammatory  thickening  will  be  discerned.  A  punctate 
hemorrhage  often  follows  removal  of  the  scales  by  scratching. 
There  is  no  watery  discharge  at  any  time.  The  skin  between  the 
patches  is  perfectly  healthy. 

While  the  anatomic  lesions  are  always  identical,  the  eruption 
assumes  such  features,  in  the  size  and  shape  of  the  patches,  to 
give  rise  to  special  names : 

Psoriasis  Punctata. — The  eruption  occurs  as  small,  rounded 
patches,  about  the  size  of  a  pin's  head.  This  is  a  rare  variety. 
The  lesion  rapidly  increases  in  size. 

Psoriasis  Gtittata. — The  eruption  occurs  in  the  form  and  size  of 
drops,  and  when  covered  with  scales  gives  the  skin  the  appear- 
ance of  having  been  splashed  with  mortar.  A  quite  frequent 
variety. 

Psoriasis  Nummularis. — ^The  eruption  resembles  variously 
sized  coins. 

Psoriasis  Circinata. — The  eruption  is  about  the  size  of  the 
former  variety,  the  center  clearing  away,  leaving  the  skin  normal. 


PSORIASIS.  775 

although  it  may  continue  to  enlarge  at  the  periphery,  after  the 
manner  of  tinea  circinata. 

Psoriasis  Gyrata. — The  eruption  in  wavy  lines,  of  the  width  of 
about  half  an  inch,  resembling  circles  and  semicircles.  This 
variety  is  a  continuation  of  the  former,  from  the  joining  of  the 
patches  of  psoriasis  circinata. 

Psoriasis  Diffusa. — The  patches  of  eruption  are  large  and  of 
irregular  shape,  covering  a  considerable  amount  of  surface.  This 
variety  occurs  more  frequently  on  the  front  of  the  leg  and  the 
outer  aspect  of  the  forearm. 

Psoriasis  Palmaris  et  Plantar  is  .—In  these  lesions  the  eruption 
is  characterized  by  larger,  thicker,  and  less  lustrous  scales,  and 
by  the  occurrence  of  deep  and  painful  fissures,  from  which  exudes 
either  a  serous  or  sanguineous  fluid. 

Psoriasis  Unguium. — In  psoriasis  of  the  nails  they  become 
thickened,  opaque,  grayish  in  color,  deeply  grooved  transversely, 
and  often  pitted,  and  in  rare  cases  the  nails  are  replaced  by  a 
scaly  incrustation. 

Any  portion  of  the  body  is  liable  to  be  attacked  with  psoriasis, 
but  the  elbows,  knees,  and  scalp  are  involved  with  greatest  fre- 
quency. The  only  discomfort  the  patient  suffers  is  from  the  itch- 
ing, which  at  times  is  very  severe  and  distressing.  The  disease 
is  essentially  chronic.  Few  cases  become  permanently  cured  but 
the  affection  shows  spontaneous  improvement  in  the  summer 
months  in  many  cases.  The  eruption  may  partially  or  completely 
disappear  with  or  without  treatment,  but  recurrence  is  to  be 
expected. 

Diagnosis. — A  typical  attack  of  psoriasis  presents  no  difficulty 
in  diagnosis.  There  are  a  few  affections,  however,  which  may 
be  confounding  in  irregular  cases. 

Squamous  eczema  occurring  in  patches  may  be  confused  with 
psoriasis.  In  the  former  the  tendency  is  to  involve  flexor  sur- 
faces, itching  is  severe,  the  patches  are  irregular  and  do  not  clear 
in  the  center,  there  is  usually  a  history  of  moisture,  there  are  no 
silvery  imbricated  scales,  and  there  is  decided  inflltration  and 
thickening. 

Papulosquamous  syphilis  may  be  distinguished  from  psoriasis 


776  PSORIASIS. 

by  its  history,  concomitant  signs,  distribution,  absence  of  itching, 
multiformity  of  the  lesions,  scanty  scaling,  and  deep-seated 
infiltration. 

Tinea  circinata  is  characterized  by  more  inflammatory  lesions 
and  the  presence  of  the  fungus  in  the  scales  which  are  not  abundant. 

Seborrhea  of  the  scalp  and  psoriasis  of  the  same  region  are 
frequently  confounded.  In  the  former  the  scalp  is  paler,  the 
scales  are  finer,  smaller,  more  generally  diffused,  of  a  grayish 
or  yellowish  color,  and  greasy,  sebaceous  character.  Psoriasis 
of  the  scalp  occurs  in  patches,  which  are  reddish  and  infiltrated, 
and  there  are  almost  always  patches  of  the  disease  on  other  parts 
of  the  body. 

Prognosis. — Removal  of  the  eruption  is  by  no  means  difficult. 
Relapses  are  common.     A  permanent  cure  can  never  be  assured. 

Treatment. — The  constitutional  treatment  includes  attention  to 
the  diet  and  hygiene  and  the  relief  of  any  rheumatic,  gouty,  or 
gastrointestinal  disorders.  The  most  valuable  remedy  is  arsenic, 
either  in  solution  or  pill  form,  but  it  should  not  be  administered 
when  the  eruption  is  markedly  inflammatory.  Potassium  iodid, 
salicylates,  thyroid  extract,  and  the  alkalies  are  of  benefit  in  cer- 
tain cases. 

Locally,  the  scales  should  first  be  removed  by  bathing  or  by 
means  of  unctuous  substances.  In  the  early  stage  when  the 
symptoms  are  highly  inflammatory,  soothing  applications  are  to 
be  employed.  Usually  stimulation  is  required  and  for  this  pur- 
pose tar  is  of  great  value.     The  following  is  frequently  employed : 

I^.      Olei  cadini 5i  4 .  gm. 

Petrolat Bi  32.  gm. 

M.  S. — Apply  locally  twice  daily. 

Or— 

I^.     Olei  cadini, 

Olei  amygdalae  dulc  ... aa    3ss  16,  c.c. 

M.  S. — Apply  locally  twice  daily. 

Or— 

I^.     Ung.  picis  (U.  S.  P.) 5i  4.gm. 

Petrolat oi  32  .  gm. 

M.  S. — Apply  locally  twice  daily. 


PITYRIASIS    ROSEA.  777 

The  following  formula  suggested  by  G.  H.  Fox  is  of  benefit: 

I^.      Chrysarobini     gr.  x  to  xx  to  5  j  o  .  65  to  i  .  3  to  4  gm. 

^theris  et  alcoholis.  aa  q.  s.  Q- s. 

Collodii f  5j  30.C.C. 

M.  S. — Rub  the  chrysarobin  with  a  little  alcohol  and  ether, 
and  add  to  the  collodion.  Apply  to  the  affected  patch  by 
means  of  a  camel's-hair  brush,  after  removal  of  the  scales. 

The  objection  to  chrysarobin  in  ointment  form  is  that  it 
stains  the  clothing;  the  following,  however,  may  be  employed 
with  good  results. 

I^      Chrysarobini gr.  x  to  xv  to  xxx  o .  6  to  i  to  2  gm. 

Petrolat 5j  32.  gm . 

M.  S. — Apply  to  each  spot  twice  daily. 

In  using  chrysarobin,  care  should  be  taken  not  to  have  the 
preparation  of  too  great  a  strength  and  not  to  apply  it  over  too 
large  an  area,  otherw^ise  a  dermatitis  may  result. 

Among  other  local  remedies  of  value  may  be  mentioned  sul- 
phur, ammoniated  mercury,  salicylic  acid,  green  soap,  pyro- 
gallic  acid,  and  resorcin.  The  application  of  the  x-Ta.y  is  of 
benefit  in  removing  the  lesions  but  has  no  effect  in  preventing 
recurrence. 

PITYRIASIS  ROSEA. 

Synonyms. — Pityriasis  maculata  et  circinata;  herpes  tonsur- 
ans maculosus. 

Description. — An  acute,  self-limited,  inflammatory  disease, 
characterized  by  the  appearance  of  pinkish  or  rose  colored  mac- 
ules and  macidopapules  occurring  in  oval  patches  occupying 
chiefly  the  trunk  and  thighs.  Many  of  the  patches  tend  to 
clear  up  in  the  center  and  spread  on  the  periphery.  The  cen- 
tral portion  of  each  patch  presents  a  somewhat  yellowish  ap- 
pearance while  the  border  is  pinkish,  elevated,  and  covered  with 
small  scales.  Slight  itching  may  be  present.  The  affection 
may  be  attended  by  mild  constitutional  reaction.      The  course 


77^  DERMATITIS. 

is  from  four  to  eight  weeks,  the  eruption  undergoing  involu- 
tion spontaneously  and  being  uninfluenced  by  treatment.  The 
course,  location,  and  character  of  the  lesions  will  distinguish 
this  eruption  from  other  circinate  diseases  such  as  psoriasis, 
seborrheic  eczema,  syphilis,  and  ringworm. 

DERMATITIS. 

Inflammation  of  the  skin  as  the  result  of  local  irritation.  The 
symptoms  are  the  ordinary  phenomena  of  inflammation  in 
general,  redness,  heat,  swelling,  pain,  and  tenderness. 

Dermatitis  traumatica  is  that  form  of  the  affection  due  di- 
rectly to  local  injury. 

Dermatitis  calorica  is  the  variety  which  is  produced  by  ex- 
posure to  extremes  of  heat  (burns)  or  cold  (frost-bite).  Various 
grades  of  reaction  are  observed  according  to  the  severity  of  the 
exposure.  Three  stages  occur  in  both  forms,  erythema,  vesica- 
tion, and  gangrene. 

Treatment. — For  burns,  a  solution  of  sodium  bicarbonate  or 
carron  oil  (equal  parts  of  linseed  oil  and  lime-water)  is  of  great 
value.  For  frost-bite,  first  rubbing  the  part  with  snow  and  later 
applying  ichthyol  ointment  (5i  to  the  ounce)  is  a  very  efficient 
mode  of  treatment. 

Dermatitis  venenata  is  the  form  of  the  condition  that  arises 
from  contact  with  poisonous  plants  and  chemical  irritants. 
The  most  common  variety  of  this  is  that  following  exposure  (in 
susceptible  individuals)  to  the  poison  ivy  (rhus  toxicodendron), 
poison  oak  (rhus  venenata),  and  poison  sumach  (rhus  diversi- 
bola).  Among  other  plants  capable  of  inducing  this  condition 
may  be  mentioned  the  trumpet  vine,  dogwood,  common  radishes, 
common  field  daisy,  star  cucumber,  and  certain  fungi.  Among 
irritant  drugs  frequently  inducing  this  inflammation  are  mus- 
tard, croton  oil,  cantharides,  iodoform,  dye-stuffs,  tobacco, 
arnica,  liniments  of  various  kinds,  turpentine,  acid,  alkalies, 
etc.  Any  substance  employed  for  the  treatment  of  disease 
of  the  skin  when  used  in  excess  may  cause  the  condition.  Indi- 
viduals engaged  in  trades  necessitating  the  constant  handling  of 


DERMATITIS.  779 

flour,  sugar,  pastes,  and  similar  substances  frequently  develop 
this  affection.  Excessive  exposure  to  the  .Y-ray  or  Finsen  lamp 
gives  rise  to  dermatitis.  Many  other  substances,  not  mentioned 
here,  may  induce  an  artificial  inflammation  if  the  integument  is 
susceptible  to  their  influence. 

Symptoms. — The  earliest  manifestation  is  diffuse  erythema. 
If  the  irritation  was  not  very  severe  the  affection  may  subside 
after  the  occurrence  of  erythema  and  slight  swelling.  Usually, 
however,  the  swelling  becomes  more  intense  and  innumerable 
vesicles  and  blebs  form  on  the  affected  regions,  accompanied 
by  almost  intolerable  burning  and  itching.  In  the  ordinary 
case  due  to  rhus  poisoning,  the  hands,  face,  and  genitalia  are 
the  regions  most  often  involved.  These  symptoms  usually 
subside  spontaneously  within  a  week  or  ten  days,  but  may  be 
prolonged  by  continued  exposure  and  improper  treatment. 

Treatment. — In  all  cases,  the  irritant  should  be  withdrawn  at 
once.  Sedative  lotions  are  most  efficacious  in  subduing  the  in- 
flammation. One  of  the  most  soothing  is  a  saturated  aqueous 
solution  of  boric  acid  containing  ten  minims  (0.6  c.c).  of  glyc- 
erin to  the  ounce.  Sodium  hyposulphite  solution  (oi  to  the 
ounce),  dilute  fluidextract  of  grindelia  robusta  (oi  to  4  ounces 
of  water),  and  lotio  nigra  and  lime-water  are  also  very  beneficial. 
The  itching  may  be  relieved  by  the  addition  of  carbolic  acid  (10 
minims  to  the  ounce)  and  glycerin  (10  minims)  to  any  of  the 
preparations.  The  great  danger  lies  in  overtreating,  in  an  effort 
to  allay  the  itching  and  burning. 

Dermatitis  medicamentosa  is  the  term  applied  to  the  various 
cutaneous  manifestations  that  are  due  directly  to  the  internal 
administration  of  certain  drugs.  This  form  is  influenced  by 
individual  susceptibility,  elimination  through  the  skin,  large 
dosage,  and  long-continued  administration. 

The  hromids  produce  an  eruption  consisting  of  papules  and  pus- 
tules resembling  acne  in  many  respects  but  having  a  more  inflam- 
matory appearance.  Occasionally,  the  eruption  consists  of 
macules,  bullce,  and  even  fungating  nodules,  the  latter  being 
most  common  in  children. 

The  iodids  usually  give  rise  to  an  acneiform    eruption  but 


780  FURUNCULUS. 

may  produce  bullous,  papular,  or  erythematous  cutaneous 
manifestations . 

Cubebs  and  copaiba  in  susceptible  individuals  give  rise  to 
erythema,  macules,  and  papules,  the  eruption  often  resem- 
bling urticaria  or  erythema  multiforme. 

Antipyrin  and  other  coal-tar  products  are  not  infrequently  fol- 
lowed by  morbilliform,  erythematopapular,  or  urticarial  erup- 
tions which  are  prone  to  itch  and  desquamate. 

Belladonna  and  its  alkaloid  atropin  occasionally  induce  a 
diffuse  erythematous  eruption  on  the  face,  neck,  and  chest 
resembling  scarlet  fever.  Associated  with  it  are  dryness  of  the 
throat,  dilatation  of  the  pupils,  and  mild  delirium. 

Arsenical  preparations  may  give  rise  to  urticarial,  erythema- 
tous, papular,  or  vesicular  manifestations.  Long-continued 
administration  is  often  followed  by  pigmentation  of  the  skin. 

Chloral  occasionally  produces  an  erythematous  or  an  urti- 
carial eruption. 

Quinin  in  susceptible  persons  may  be  followed  by  erythem.- 
atous,  urticarial,  purpuric,  or  vesicular  eruptions. 

Optum  and  its  derivatives  may  give  rise  to  pruritus,  erythema, 
papules,  or  wheals. 

Serums  employed  for  antitoxin  purposes  are  not  uncommonly 
followed  by  urticarial  eruptions. 

Dermatitis  factitia  is  the  term  applied  to  eruptions  produced 
by  the  patient  for  the  purpose  of  exciting  sympathy  or  atten- 
tion. They  resemble  none  of  the  well-recognized  diseases  and 
the  diagnosis  is  always  difficult.  The  lesions  usually  occur  sud- 
denly on  accessible  regions.  The  patients  are  mostly  hysteric 
women  or  malingerers. 

Dermatitis  exfoliativa  is  a  very  unusual  affection,  in  which 
the  inflammation  is  attended  with  high  fever  and  followed  by 
extensive  desquamation. 

FURUNCULUS. 

Synonyms. — Boil;  furuncle;  furunculosis. 

Definition. — An  acute  affection  of  the  skin,  characterized  by 
the  occurrence  of  one  or  more  circumscribed  cutaneous  or  sub- 


FURUNCULUS.  781 

cutaneous  abscesses  (boils),  which  usually  terminate  by  necrosis 
of  the  central  tissue,  with  its  subsequent  expulsion  in  the  form 
of  pus  or  a  core,  and  a  resulting  cicatrix. 

Causes. — The  exciting  cause  is  infection  of  the  hair-follicles 
with  pus-producing  microorganisms.  As  contributory  causes 
may  be  mentioned  general  debility,  anemia,  diabetes,  uremia, 
local  friction  or  injury,  uncleanliness,  and  contact  with  certain 
irritants,  particularly  tar  and  petroleum. 

Pathology. — The  process  resulting  in  a  "boil"  has  its  origin  in 
either  a  sebaceous  gland,  a  sweat  gland,  or  a  hair  follicle,  and 
never  begins  in  the  meshes  of  the  corium.  "  It  begins  as  a  small, 
roundish  spot  which  increases  in  size  until  certain  dimensions 
are  attained,  when  it  undergoes  suppurative  change,  resulting  in 
the  formation  of  a  central  point  or  core,  composed  of  the  tissue 
of  the  gland  in  which  the  furuncle  originated,  which,  together 
with  the  pus,  is  cast  off.  It  shows  no  disposition  to  become  dif- 
fuse, being  always  a  circumscribed  inflammation.  After  the  dis- 
charge of  the  core  a  cavity  of  more  or  less  depth  remains,  show- 
•  ing  the  tissue  around  it  to  be  hard  and  infiltrated.  After  a  few 
days  or  a  week  it  fills  up  by  granulation,  leaving  a  cicatrix  which 
is  often  permanent.  The  central  point  or  core,  when  thrown  off, 
is  composed  of  a  whitish,  totigh,  pultaceous  mass  of  dead  tissue, 
varying  in  size  with  the  extent  and  depth  of  the  inflammation" 
(Duhring). 

The  staphylococcus  pyogenes  aureus  is  the  microorganism  re- 
sponsible for  the  condition  in  most  cases.  The  tricophyton 
fungus  is  occasionally  the  exciting  cause. 

Symptoms. — "  Boils"  may  occur  singly,  or  more  commonly  in 
crops  of  two,  three,  or  more,  another  crop  following  their  disap- 
pearance (furunculosis) . 

The  abscess  begins  as  a  small,  rounded,  imperfectly  defined, 
isolated,  reddish  spot,  of  a  highly  inflamed  character,  painful 
on  pressure,  its  size  gradually  increasing,  its  central  point  pre- 
senting evidences  of  suppuration.  It  reaches  its  full  develop- 
ment in  about  a  week,  when  it  consists  of  a  slightly  raised, 
rounded,  and  pointed  inflammatory  swelling,  with  a  yellowish 
point  in  the  center — the   "core."      Abscesses   with   no   central 


782  CARBUNCULUS. 

suppuration  or  core  are  called  "blind  boils."  The  size  of  a 
developed  boil  varies  from  a  split-pea  to  a  walnut,  the  color 
deep  red,  with  a  yellow  center,  surrounded  by  a  slight  areola. 
The  pain  of  a  boil  is  dull  and  throbbing,  increased  on  pressure, 
and  usually  worse  at  night.  The  constitutional  symptoms  are 
mild  or  severe,  according  to  the  number  and  size  of  the  lesions. 

Any  portion  of  the  body  may  be  attacked;  its  preference,  how- 
ever, is  for  the  face,  neck,  back,  axillae,  nipples,  buttocks,  anus, 
perineum,  and  labia. 

Prognosis. — Single  lesions  usually  pass  through  their  course 
without  affecting  the  general  condition  of  the  patient.  Furun- 
culosis  may  be  very  difficult  to  relieve  and  may  impair  the  gen- 
eral health. 

Treatment. — In  all  cases  of  continuous  furuncle  formation, 
the  urine  should  be  examined  and  any  organic  disease  promptly 
treated.  In  these  cases  tonics  such  as  iron,  quinin,  and  strych- 
nin should  be  administered.  It  is  a  common  practice,  even 
when  the  lesions  are  single,  to  administer  calcium  sulphid,  gr. 
i/io  to  1/8  (0.0065  to  0.008  gm.),  every  two  or  three  hours. 
The  efficac}^  of  this  treatment  is  doubtful. 

Locally,  warm  applications  often  aid  in  hastening  suppuration, 
which  when  it  has  occurred  indicates  early  incision  to  allow 
expulsion  of  "  the  core.  "  Shaving  of  the  hair  in  the  immediate 
vicinity  frequently  prevents  infection  of  adjacent  follicles.  If 
the  lesion  is  exposed  to  friction  it  should  be  protected  by  soap- 
plaster  or  adhesive  plaster.  Among  the  various  methods  recom- 
mended for  aborting  furuncles  may  be  mentioned  crucial  inci- 
sions, injection  of  2  to  5  drops  of  carbolic  acid  (5  per  cent,  solu- 
tion) into  the  apex  of  the  boil,  and  the  application  of  equal  parts 
of  glycerin  and  extract  of  belladonna  or  the  ointment  of  nitrate 
of  mercury.  Ichthyol  ointment  (25  per  cent.)  is  of  great 
value. 

CARBUNCULUS. 

Synonyms. — Carbuncle;  anthrax  benigna. 

Definition. — An  indurated,  more  or  less  circumscribed,  dark 
red,  painful,  deep-seated  inflammation  of  the  skin  and  subcu- 


CARBUNCULUS.  783 

taneous  connective  tissue,  terminating  in  a  slough  and  the  sub- 
sequent production  of  a  permanent  cicatrix. 

Causes. — The  exciting  cause  is  some  pathogenic  microorganism. 
The  affection  usually  occurs  in  middle-aged  individuals  and  in 
men  more  often  than  in  women.  Impairment  of  the  general 
health,  diabetes,  and  local  injur>^  are  also  factors  in  its  production. 

Pathology. — Although  Billroth  regards  furuncle  and  carbuncle 
as  differing  only  in  degree,  the  explanation  of  Warren,  of  Boston, 
seems  the  more  probable,  he  being  the  first  to  call  the  attention 
of  histologists  "to  the  existence  of  small  columns  of  adipose  tissue 
leading  from  the  panniculus  adiposus  up  to  the  roots  of  the 
lanugo  hairs,  taking  an  oblique  direction  in  a  line  with  the  erec- 
tores  pilorum.  The  inflammation  resulting  in  suppuration  of  the 
subcutaneous  adipose  tissue  must  either  form  an  abscess  or  be- 
come diffuse.  In  phlegmonous  erysipelas  the  latter  condition  is 
observed;  but  when  the  inflammation  is  in  the  dermoid  texture, 
the  exudates  infiltrate  the  skin  and  naturally  follow^  the  canals 
occupied  by  the  'columnae  adiposae. '  The  pressure  thus  exerted 
•upon  the  dermoid  tissue  cannot  fail  to  strangulate  the  circulation 
and  thus  produce  gangrene  of  the  tissue,  even  if  the  exudate  be 
not  poisonous  enough  to  destroy  the  cells  by  its  presence.  It  can 
by  this  explanation  be  easily  understood  why  this  disease  is  apt 
to  affect  the  skin  on  the  nape  of  the  neck  and  the  back  more 
than  on  other  parts  of  the  body.  At  this  point  the  skin  is  dense, 
its  fibrous  element  extending  deep  into  the  adipose  layer,  which 
is  surrounded  by  strong  bands;  hence,  the  pus  confined  in 
such  a  place,  seeking  the  easiest  outlet,  will  travel  along  these 
miniature  adipose  canals,  producing  the  peculiar  appearance 
pathognomonic  of  carbuncle. ' ' 

Symptoms, — The  affection  is  usually  manifested  by  a  single 
lesion  which  occurs  with  greatest  frequency  on  the  back  of  the 
neck,  shoulders,  or  between  the  scapulse.  It  begins  in  the  lower 
layers  of  the  integument  and  it  first  resembles  a  phlegmon  but  is 
devoid  of  its  bright  redness.  It  is  surrounded  in  the  early  stages 
and  vesicles  may  be  present.  Soon  the  affected  area  becomes 
firm,  circular,  flat,  and  raised  above  the  surrounding  parts  with 
painful  infiltration  of  the  skin  and  subcutaneous  connective  tissue. 


784  CARBUNCULUS. 

The  size  varies  from  a  hazel  nut  to  an  orange  and  the  color  is 
violaceous.  After  a  week  or  ten  days,  the  constant  pressure 
results  in  sloughing  of  the  overlying  skin  at  numerous  points, 
through  which  necrotic  masses  and  purulent  material  are  dis- 
charged. This  gives  the  lesion  a  cribriform  appearance  which  is 
especially  characteristic.  Later  the  entire  mass  terminates  in  a 
slough,  which,  on  being  detached,  leaves  a  large,  open,  deep 
ulcer  with  firm,  everted  edges  granulating  slowly,  a  permanent 
cicatrix  marking  the  site  of  the  lesion.  The  development  of  the 
carbuncle  is  attended  by  severe  pain  of  a  deep,  throbbing,  and 
burning  character. 

Anorexia,  coated  tongue,  general  malaise,  and  moderate 
febrile  reaction  accompany  all  cases  but  vary  according  to  the 
size,  number,  and  severity  of  the  lesions.  In  very  severe  cases, 
symptoms  of  septicemia  are  superadded. 

Diagnosis. — The  characteristics  of  carbuncle  are  the  single 
lesion,  the  size,  the  phlegmonous  nature  of  the  inflammation,  the 
cribriform  appearance,  the  gangrenous  termination,  and  the 
marked  constitutional  disturbances. 

Prognosis. — The  outlook  is  never  very  favorable,  as  general 
septic  infection  is  liable  to  occur  at  all  times.  It  is  most  serious 
when  occurring  in  the  aged,  alcoholics,  diabetics,  and  greatly  de- 
bilitated subjects  and  when  situated  on  the  upper  lip  (an  unusual 
location).  In  ordinary  cases  the  prognosis  is  not  so  grave  but 
the  possibility  of  general  infection  should  always  be  borne  in 
mind.  ■ 

Treatment. — Constitutional  treatment  is  of  great  importance. 
Nutritious  diet,  stimulants,  and  full  doses  of  remedies  such  as 
tincture  of  the  chlorid  of  iron,  quinin  sulphate,  arsenic,  strychnin, 
and  ammonium  chlorid  should  be  prescribed.  Calcium  sulphid, 
gr.  1/8  (0.008  gm.),  every  two  hours,  is  of  benefit  in  some  cases. 
Opium,  chloral,  or  phenacetin  may  be  necessary  to  relieve  the 
pain. 

Locally,  the  injection  of  a  saturated  solution  of  pure  carbolic 
acid  through  the  several  apertures  of  the  lesion  in  every  direc- 
tion through  the  sloughing  tissue,  is  often  very  beneficial.  It 
produces  severe  pain  for  a  short  time  afterward.     The  injection 


TINEA   CIRCESTATA.  785 

of  10  to  20  minims  of  a  5  per  cent,  solution  of  carbolic  acid  in 
glycerin,  into  the  lesion  very  early  in  its  course,  may  serve  to 
abort  it.  The  application  of  stick  caustic  potash  directly  into 
the  openings  of  the  carbuncle  is  also  of  value.  Crucial  incision 
may  be  employed  at  times.  Strapping  of  the  lesion  by  means 
of  adhesive  strips  applied  in  concentric  squares,  painting  with 
cantharidal  collodion  or  tincture  of  iodin,  or  the  daily  applica- 
tion of  nitrate  of  mercury  ointment  may  also  be  used.  With 
the  occurrence  of  necrosis,  hot  antiseptic  solutions  should  be 
applied  to  aid  in  separation  of  the  gangrenous  slough.  If 
septicemia  threatens  the  necrotic  tissues  should  be  excised. 


PARASITIC  DISEASES. 

TINEA  CIRCINATA. 

Synonyms. — Tinea  trichophytina  corporis;  herpes  circinatus; 
ringworm  of  the  body. 

Definition. — A  contagious,  vegetable  parasitic  affection  of  the 
skin,  due  to  the  trichophyton  fungus,  characterized  by  the  de- 
velopment of  one  or  more  circular  or  irregularly  shaped,  var- 
iously sized,  inflammatory,  slightly'  vesicular  or  squamous 
patches,  occurring  upon  the  general  surface  of  the  body. 

Causes. — Ringworm  of  the  body  is  caused  by  the  presence  of  a 
vegetable  parasite,  termed  the  trichophyton,  the  same  growth  or 
fungus  that  produces  tinea  tonsurans  and  tinea  sycosis.  The 
affection  is  highly  contagious  and  is  frequently  communicated 
from  one  individual  to  another,  although  it  has  been  determined 
that  a  certain  unknown  condition  of  the  skin  is  requisite  for  its 
development.  In  children  it  is  most  frequently  seen  among  the 
weakly  and  the  poorly  nourished.  In  adults  it  is  usually  associ- 
ated with  a  decline  in  the  general  health. 

Pathology. — The  fungus  is  seated  between  the  strata  of  the 

epidermis,  more  particularly  in  the  superior  layers  of  the  rete. 

Mycelium,  consisting  of  long,  slender,  jointed  threads  may   be 

found  in  abundance  but  spores  are  very  scant.     The  presence 

50 


786  TINEA   CIRCINATA. 

of  this  foreign  body  produces  the  subsequent  phenomena — a 
superficial  dermatitis,  erythema,  exudation,  minute  vesicula- 
tion,  and  papulation,  and,  in  the  severe  grades,  tubercles  and 
pustules.  The  desquamative  symptoms  are  exfoliative — 
nature's  efforts  for  relief.  ' 

Symptoms. — Tinea  circinata  varies  greatly  in  the  degree  of  its 
development,  from  the  trivial  complaint  so  often  seen  in  children 
to  the  chronic,  extensive,  and  obstinate  disease  sometimes  seen 
about  the  thighs  in  adults  {tinea  circinata  cruris). 

The  disease  usually  begins  as  a  small,  reddish,  scaly,  rounded 
or  irregularly  shaped  spot  of  papules,  which  in  a  very  few  days 
assumes  a  circular  form  (ringworm).  It  continties  to  increase 
in  size,  the  papules  often  changing  to  vesicles.  A  characteristic 
of  the  eruption  is  its  healing  in  the  center  as  it  spreads  on  the 
periphery.  Occasionally  the  circles  or  rings  coalesce,  forming 
serpiginous  lesions.  The  usual  size  of  a  fully  developed  ring- 
worm is  about  that  of  a  silver  quarter  of  a  dollar.  The  affection 
occurs  with  greatest  frequency  upon  the  face,  neck,  and  backs  of 
the  hands.     Itching  is  slight  as  a  rule. 

Chronic  tinea  circinata  often  lacks  the  characteristic  annular 
configuration,  but  instead  appears  in  the  form  of  single  or  mul- 
tiple, disseminated,  small,  reddish,  slightly  scaly,  ill-defined 
spots  which  may  or  may  not  be  elevated  above  the  surrounding 
skin.  The  size  varies,  and  the  line  of  demarcation  between  the 
lesion  and  the  healthy  skin  may  be  lacking. 

The  "  eczema  marginatum  "  of  Hebra  is  to  be  looked  upon  as  a 
severe  form  of  tinea  circinata. 

Tinea  circinata  cruris,  or  ringworm  of  the  thighs,  a  variety  of 
the  "eczema  marginatum"  of  Hebra,  is  usually  complicated 
with  true  eczema,  and  is  a  very  obstinate,  chronic  form  of  the 
affection;  it  is  accompanied  by  severe  itching. 

Tinea  trichophytina  unguium  is  a  variety.  The  nails  become 
opaque,  whitish,  thickened,  and  soft  and  brittle,  especially  along 
their  free  border.  Its  course  is  chronic,  and  it  is  difl&cult  to 
cure. 

Diagnosis. — While  in  many  cases,  the  history,  course,  charac- 
ter of  the  eruption,  etc.,  will  serve  to  distinguish  tinea  circinata 


TINEA   CIRCINATA.  787 

from  other  circinate  eruptions,  the  diagnosis  should  always  be 
rendered  positive  by  a  microscopic  examination  of  the  scales 
removed  from  the  lesion.  The  scales  should  be  placed  upon  a 
glass  slide  containing  a  drop  of  liquor  potassse  over  which  is 
laid  a  thin  glass  cover.  After  remaining  for  a  few  minutes, 
the  fungus  may  be  detected  by  a  microscope  having  a  magni- 
fying power  of  from  250  to  500  diameters. 

Prognosis. — The  affection  is  usually  very  amenable  to  treat- 
ment but  occasionally  it  exhibits  great  obstinacy.  At  times  re- 
lapses occur. 

Treatment. — Local  applications  usually  suffice  to  cure  the 
affection.  The  patch  should  be  washed  with  soap  and  water 
and  one  of  the  following  supplied: 

I^.      Cupri  acetat gr.  x  0.6  gm. 

Ung.  aquae  ros« 5  j  32  .     gm. 

M.  S. — Apply  locally  twice  daily. 

Or— 

I^.      Hydrargyri  ammoniat. .  .    gr.  xx  to  xxx     1.3  to  2  .  gm. 
Petrolat §j  32.  gm. 

M.  S. — Apply  locally  twice  daily. 

Or— 

I^.      Hydrargyri  chloridi  cor.    gr.j  0.065  g^^- 

Tinct.  benzoin,  comp. .  .  .    f  §j  30.  c.c. 

M.  S. — Apply  locally  twice  daily. 

Or— 

I^.      Sulph.  precip oi  4 .  gm. 

Acid,  boric oi  4.  gm. 

Petrolat oi  32.  gm. 

M.  S. — Apply  locally  twice  daily. 

Or— 

I^       Sodii  hyposulphit 5i  4.  gm. 

Aquas f  §i  30.  c.c. 

M.  S. — Apply  locally  twice  daily. 

Among  other  remedies  of  value  may  be  mentioned  tar,  resor- 
cin,  betanaphthol,  chrysarobin,  protargol,  and  sublamin. 

In  obstinate  cases  of  tinea  cruris,  the  parts  should  be  treated 


788  TINEA   TONSURANS. 

with  a  saturated  solution  of  boric  acid  and  afterward  covered 
with  boric-acid  powder  or  ammoniated  mercury  ointment  (gr. 
XXX  to  5i). 

TINEA  TONSURANS. 

Synonyms. — Tinea  trichophytina  capitis;  herpes  tonsurans; 
ringworm  of  the  scalp. 

Definition. — A  contagious,  parasitic  affection  of  the  scalp, 
due  to  the  trichophyton  fungus,  characterized  by  the  develop- 
ment of  circumscribed,  vesicular  or  squamous,  more  or  less 
bald  patches  in  which  the  hair  is  diseased  and  usually  broken 
off  close  to  the  scalp. 

Cause. — It  results  from  the  presence  and  growth  of  the  same 
fungus  giving  rise  to  tinea  circinata — trichophyton.  It  is  an  affec- 
tion of  childhood,  seldom  being  seen  after  puberty.  It  is  highly 
contagious,  and  may  be  contracted  from  a  case  of  ringworm  of 
the  body. 

Pathology.— The  fungus  invades  the  hair,  hair- follicles,  and 
adjacent  epidermis  causing  disintegration  of  the  hair  and  dis- 
tention of  the  follicle  which  becomes  prominently  raised.  Spores 
are  present  in  abundance  but  the  mycelium  is  very  scant. 
The  hair-shaft  is  fractured  just  above  the  level  of  the  scalp,  and 
usually  presents  a  jagged,  bristly,  stubble-like  extremity.  The 
epidermis  of  the  scalp  may  either  present  minute  vesicles  and 
desquamation,  or,  in  severe  cases,  edema  and  inflammatory 
symptoms,  with  fluid  exudation  {tinea  kerion). 

Symptoms. — Ringworm  of  the  scalp  usually  begins  in  the  form 
of  small  circumscribed  patches,  which  soon  become  the  seat  of 
small  vesicles  or  pustules,  terminating  in  desquamation,  or  of 
furfuraceous  scales.  The  patches  spread  rapidly,  soon  reach- 
ing the  size  of  a  silver  quarter  to  that  of  a  silver  dollar.  They 
are  circular  in  form,  circumscribed,  of  a  reddish,  grayish,  or 
greenish-yellow  color,  and  covered  with  fine  or  coarse  scales, 
with  the  hairs  broken  off  close  to  the  scalp.  The  epidermis  of 
the  scalp  is  more  or  less  raised,  and  the  follicles  are  prominent, 
giving  the  characteristic  appearance  of  the  disease — the  goose- 


TINEA   TONSURANS.  789 

skin  or  plucked-fowl  appearance.  As  a  result  of  the  loss  of  hair, 
baldness,  more  or  less  complete,  but  temporary,  exists.  Itch- 
ing is  a  constant  symptom. 

Ringworm  of  the  face  or  body  {tinea  circinata)  may  complicate 
tinea  tonsurans. 

Tinea  kerion  is  a  severe  variety  of  tinea  tonsurans,  "  charac- 
terized by  edema,  inflammation,  and  the  exudation  of  a  viscid, 
glutinous,  yellowish  secretion  from  the  opening  of  the  hair- 
follicles.  When  fully  developed  the  patches  are  yellowish, 
reddish,  or  purple  in  color,  and  are  more  or  less  raised,  edema- 
tous, and  boggy.  They  are  uneven  and  honeycomb-like  (hence 
the  name  kerion),  and  studded  with  yellowish,  suppurative 
points,  or,  later  with  small  cavities  or  foramina,  the  openings 
of  the  distended  hair-follicles  deprived  of  their  hairs,  which 
discharge  a  mucoid,  gummy,  honey-like  fluid."  The  patches 
are  tender,  painful,  and  at  times  the  seat  of  itching. 

Diagnosis. — The  affection  is  usually  readily  differentiated 
from  other  diseases  of  the  scalp  by  its  occurrence  in  children, 
in  the  shape  of  circumscribed,  sharply  marginated,  more  or  less 
circular  patches  of  incomplete  baldness  characterized  by  broken - 
off  hairs,  very  prominent  follicles,  and  grayish  scales.  The 
presence  of  the  fungus  is  diagnostic.  A  hair  should  be  ex- 
tracted, and  examined  after  being  immersed  in  liquor 
potassge. 

Prognosis. — The  disease  is  essentially  chronic.  If  untreated 
it  may  persist  for  two  or  three  years  or  until  puberty,  when  its 
soil  seems  to  be  exhausted  and  the  affection  subsides.  Even 
under  treatment  the  patches  may  last  for  six  months  or 
more. 

Treatment. — Local  treatment  only  is  required,  and  it  should 
be  vigorous  and  persistent.  No  case  should  be  discharged  un- 
til the  microscope  shows  absence  of  the  fungus  in  the  extracted 
hairs.  Mild  cases  should  be  treated  by  cutting  the  hair  as 
close  as  possible  and  thoroughly  scrubbing  the  patches  with 
green  soap  and  water  or  by  the  application  of  a  25  to  50  per 
cent,  solution  of  boroglycerin,  twice  daily,  or  a  6  per  cent,  solu- 
tion of  the  oleate  of  mercury,  or  one  of  the   following: 


790 


TINEA   TONSURANS. 


^.     Sulph.  precip oi 

Petrolat Bi 

M.  S. — Apply  locally  twice  daily. 

I^.      Betanaphthol oi 

Petrolat 3i 

M.  S. — Apply  locally  twice  daily. 

I^.     Protargol gr.  xxiv 

Petrolat 5  i 

M.  S. — Apply  locally  twice  daily. 

I^.      Sodii  borat oi 

Aquae  destil f  oii 


4. 

gm 

32. 

gm 

4. 

gm 

32. 

gm 

1-5  gm 
32.     gm 


M.  S. — Apply  thoroughly  several  times  daily. 


n 


4. 

gm 

60. 

c.c. 

I . 

gm 

I  . 

gm 

47- 

gm 

2  . 

gm 

63- 

gm 

Acid,  boric gr.  xv 

Sulph.  flor gr.  XV 

Petrolat oiss 

M.  S. — Apply  to  scalp  night  and  morning. 

I^.      Cupri  oleat oss 

Petrolat Sii 

M.  S. — Apply  locally  after  washing  the  scalp  with  boric  acid 
solution. 

I^.      Thymol OSs  2 .  gm. 

Chloroformi f  5ij  8  .  c.c. 

01.  olivae f  5vj  24  .  c.c. 

M.  S. — Morris-thymol  solution.      Apply  locally. 

A  preparation  very  popular  in  London,  known  as  Coster's 
paste,  is  used  by  painting  the  patches  with  a  brush  and  allowing 
it  to  remain  on  until  the  crust  is  cast  off  in  the  course  of  five  or 
six  days,  when  it  may  be  reapplied.  A  few  applications  often 
suffice.      Its  formula  is: 

I^.     lodin oij 

Olei  picis. f5j 

M.  S. — Apply  as  directed. 

An  excellent  application  is — 

I^.      Ung.  acid,  borici.  . 5ij 

Ung.  eucalyptol Sij 

01.  caryophylli f  oss 

Glycerini q.  s. 

M.     Ft.  ung. 

S. — Apply  locally. 


8. 

gm. 

3°- 

c.c. 

63. 

gm. 

63. 

gm. 

2  . 

c.c. 

q.  s 

i. 

TINEA   SYCOSIS.  79 1 

Cases  which  resist  these  means  are  to  be  treated  by  removing 
the  loose  hairs  about  the  edges  of  the  patches  and  the  broken- 
off  hairs  over  the  surface,  by  means  of  small,  broad-bladed, 
short  forceps,  a  few  hairs  only  being  seized  at  a  time,  a  portion 
of  the  diseased  hairs  being  removed  each  day  until  the  surface 
has  been  cleared.  After  each  depilation  one  of  the  above 
formulas  vshould  be  applied. 

TINEA  SYCOSIS. 

Synonyms. — Tinea  trichophytina  barbae;  sycosis  parasitica; 
barbers'  itch;  ringworm  of  the  beard. 

Definition. — A  contagious,  parasitic  affection  of  the  hair,  hair- 
follicles,  and  subcutaneous  tissues  of  the  hairy  portion  of  the 
face  and  neck  in  the  adult  male,  due  to  the  trichophyton  fungus ; 
characterized  by   the   development   of   tubercles   and  pustules. 

Causes. — The  direct  cause  is  the  tricophyton  fungus.  Its 
growth  is  no  doubt  aided  by  some  ill-defined  impairment  of  the 
integument.  The  affection  is  usually  acquired  in  the  barber 
shop  but  may  be  contracted  from  the  lower  animals,  especially 
horses  and  cattle;  in  which  cases  it  is  of  unusual  intensity. 

Pathology. — The  parasite  finds  its  way  into  the  hair-follicles 
and  attacks  the  root  and  shaft  of  the  hair,  causing  inflammation, 
followed  by  more  or  less  follicular  suppuration  and  general  infil- 
tration of  the  surrounding  tissues.  The  presence  of  the  fungus 
also  results  in  inflammation  of  the  subcutaneous  connective 
tissue  giving  rise  to  the  well-known  tubercular  formations  pecul- 
iar to  the  affection.  They  are  firm,  comparatively  painless, 
and  manifest  but  little  disposition  to  undergo  change,  remain- 
ing during  the  presence  of  the  fungus  and  finally  disappearing 
gradually  without  leaving  a'  scar.  Under  the  microscope 
the  parasite  is  plainly  discerrible. 

Symptoms. — Barbers'  itch  begins  as  an  attack  of  tinea  cir- 
cinata,  with  one  or  more  reddish,  scaly  patches.  Soon  the  red- 
ness and  desquamation  become  more  marked  and  swelling  and 
induration  occur.  With  the  advance  of  the  disease,  the  hairs 
become  dry,   brittle,  and  loose.     The  skin  soon  becomes  dis- 


792  TINEA   SYCOSIS. 

tinctly  nodtilar  and  lumpy,  and  pustules  develop  about  the 
openings  of  the  follicles.  The  subcutaneous  tissue  is  also  in- 
volved, giving  rise  to  thick,  firm  masses  of  induration.  The 
affected  area  has  a  dark  red  or  purplish  color  and  is  studded 
with  a  large  number  of  tubercles  and  pustules.  Many  of  the 
pustules  discharge  a  purulent  material  which  accumulates, 
forming  crusts.  The  hairs  are  always  diseased  and  either  drop 
out  or  break  off  in  the  follicles  or  just  above  the  level  of  the 
surface.  The  chin,  neck,  and  submaxillary  region  are  the  most 
frequent  situations  of  the  disease.  Itching,  burning,  and  pain, 
of  varying  severity,  are  always  present.  The  affection  is  ex- 
tremely chronic  and  relapses  are  common. 

Diagnosis. — While  the  diagnosis  can  always  be  made  with  cer- 
tainty by  the  aid  of  the  microscope,  the  affection  presents  cer- 
tain clinical  characteristics  that  are  distinctive  in  very  many 
cases. 

In  tinea  sycosis,  or  sycosis  parasitica,  the  skin  and  subacuta- 
neous  connective  tissue  are  extensively  involved,  as  manifested 
by  the  induration  and  formation  of  the  characteristic  tubercles. 
The  upper  lip  is  rarely  invaded;  the  hairs  are  diseased,  broken 
off,  or  loose,  and  under  the  microscope  reveal  the  parasite. 

Sycosis  nonparasitica  is  a  chronic,  inflammatory,  noncon- 
tagious affection  of  the  hair-follicles,  characterized  by  the  devel- 
opment of  papules  and  pustules  which  are  perforated  with  hairs, 
the  hairs  themselves  being  unaffected.  The  upper  lip,  cheeks, 
and  chin  are  the  parts  mostly  involved.  If  of  long  duration, 
some  inflammatory  thickening  results. 

Pustular  eczema  may  resemble  tinea  sycosis,  with  extensive 
pustulation  and  crusting;  but  in  the  former  the  hairs  are  not  in- 
volved, nor  are  the  characteristic  tubercles  present. 

Treatment. — The  following  plaii  of  treatment  is  very  effective : 
Any  resisting  crusts  should  first  be  thoroughly  saturated  with 
almond  or  olive  oil  and  removed  by  washing  with  soft  soap  and 
water.  The  part  is  then  cleanly  shaved,  the  first  operaton  be- 
ing more  painful  than  subsequent  ones.  After  shaving,  the  face 
is  bathed  in  water  as  hot  as  can  be  borne.  All  pustules  should 
then  be  opened  with  a  fine  needle  and  the  parts  sponged  freely 


TINEA   VERSICOLOR.  793 

with  a  solution  of  sodium  hyposulphite  5i  (4  gm.),  water  fSi 
(30  c.c),  after  which  the  parts  are  again  thoroughly  washed  with 
hot  water,  carefully  dried,  and  sulphur  ointment,  3i  to  ii  (4  to  8 
gm.)  to  the  ounce  (32.  gm.),  applied.  This  procedure  should  be 
performed  preferably  at  night.  The  following  morning  the 
ointment  is  washed  off  with  soap  and  water,  the  face  bathed 
with  the  sodium  hyposulphite  solution,  and  dusted  with  any 
inert  powder.  This  plan  of  treatment  should  be  continued 
regularly  every  night,  omitting  the  shaving  when  the  beard  is 
not  sufficiently  long  enough  to  permit  it  without  great  distress. 
In  very  obstinate  cases  depilation  should  be  practised,  alternat- 
ing with  shaving.  The  various  applications  recommended  in 
the  treatment  of  tinea  tonsurans  are  also  applicable  to  this 
form  of  the  disease. 

TINEA  VERSICOLOR. 

Synonyms. — Pityriasis  versicolor;  liver-spots;  chromophytosis. 

Definition. — A  contagious  parasitic  affection  of  the  skin,  due 
to  the  microsporon  furfur,  characterized  by  the  occurrence  of 
variously  sized,  irregularly  shaped,  dry,  slightly  furfuraceous, 
yellowish  spots  upon  the  chest  or  other  portions  of  the  body. 

Cause. — Pityriasis  versicolor  is  the  result  of  the  presence  upon 
the  surface  of  the  skin  of  a  vegetable  fungus  termed  micro- 
sporon furfur.  It  is  a  mildly  contagious  affection  seen  after 
puberty.  It  is  said  to  occur  most  frequently  in  those  suffering 
from  wasting  diseases,  particularly  phthisis  pulmonalis.  It  is 
not  connected  with  any  affection  of  the  liver,  as  supposed  by 
the  laity. 

Pathology. — The  fungus  permeates  the  horny  layer  of  the 
epidermis,  never  the  hairs  or  nails,  and  gives  rise  to  the  irregu- 
larly shaped  and  sized  macules  of  a  yellowish  or  brownish  color. 
The  fungus  consists  of  short,  jointed,  angular  mycelial  threads 
and  rounded  spores  more  or  less  grouped.  As  a  rule,  it  gives 
rise  to  neither  hyperemia  nor  inflammatory  symptoms. 

Symptoms. — Tinea  versicolor  occurs  in  the  form  of  irregular, 
roundish,    circumscribed,    or   reticulated   macules.      The    spots 


794  TINEA   FAVOSA. 

vary  in  size  from  that  of  a  small  silver  coin  to  that  of  the  hand. 
By  coalescing  they  often  cover  a  greater  portion  of  the  chest, 
their  most  usual  site.  Upon  close  inspection  the  surface  of  the 
macule  is  seen  to  be  covered  with  furfuraceous  scales,  and,  if 
the  scales  be  not  visible,  scraping  with  the  finger-nail  will 
demonstrate  their  presence.  In  color  the  spots  vary  from  a 
delicate  buff  or  fawn  shade  to  a  yellowish,  deep  brown,  and, 
rarely,  even  blackish  hue.  At  times  mild  itching  accompanies 
the  eruption.  The  affection  is  chronic  and  in  the  absence  of 
treatment,  persists  indefinitely.  Response  to  treatment,  how- 
ever, is  prompt,  but  relapses  are  frequent,  due  in  all  probability 
to  a  failure  to  continue  treatment  for  a  sufficient  period. 

Diagnosis. — The  history,  course,  location,  and  character  of 
the  eruption  are  distinctive  enough  to  prevent  error,  but  in  doubt- 
ful cases  resort  should  be  made  to  the  microscope. 

Treatment. — The  parts  should  be  thoroughly  cleansed  with 
soap  and  water  and  either  of  the  following  lotions  applied: 

I^.      Sodii  hyposulphitis 5iij  12.  gm. 

Glycerini f  3ij  8  .  gm. 

Aquse ad  5iv  ad  120.  c.c. 

M.   S. — Apply  frequently. 

Or— 

I^.      Hydrargyri    chlorid    cor- 

rosiv gf-iv  0.26  gm. 

Alcoholis f  5vj  23 .       c.c. 

Ammonii  chlorid 5ss  2.       gm. 

Aquee  ros£e ad  f  ovj  178.       c.c. 

M.  S. — Apply  frequently  (Tilbury  Fox). 

TINEA  FAVOSA. 

Synonym. — Favus. 

Definition. — A  contagious  affection  of  the  skin,  due  to  a  vege- 
table parasite — Achorion  Schonleinii;  characterized  by  the  devel- 
opment of  either  dis^crete  or  confluent,  small,  circular,  cup- 
shaped,  pale-yellow,  friable  crusts,  usually  perforated  by  hairs. 

Cause. — The   presence   and  growth   of  a   vegetable   parasite 


TINEA   FAVOSA.  795 

known  as  the  A  chorion  Schonleinii  is  the  cause  of  tinea  favosa. 
It  is  more  common  in  children  than  in  adults,  attacking  the 
former  in  the  first  place  either  de  novo  or  through  direct  conta- 
gion, and  is  from  them  communicated  to  adults.  The  affection 
is  often  contracted  from  the  lower  animals.  It  is  a  disease  con- 
fined almost  exclusively  to  the  lower  classes,  especially,  of 
Russians,  Polish,  Austrians,  and  Hungarians. 

Pathology. — Tinea  favosa  may  have  its  seat  either  in  the  hair- 
follicles  and  hair,  or  upon  the  surface  of  the  skin  or  the  nails; 
the  former,  however,  being  the  structures  most  frequently  in- 
volved. The  crusts  are  made  up  almost  entirely  of  fungus, 
which  upon  section  is  seen  with  the  naked  eye  to  be  composed 
of  a  porous  mass  and  to  possess  a  pale-yellow  or  whitish  color. 
Under  the  microscope  it  is  seen  to  consist  of  both  mycelium  and 
spores    in    great    quantity   and    in   all    stages    of    development. 

Symptoms. — When  the  affection  attacks  the  hairs  and  fol- 
licles it  is  termed  tinea  favosa  pilaris;  when  the  epidermis,  tinea 
favosa  epidermidis ;  and  when  the  nails,  tinea  favosa  unguium. 
Rarely  all  the  structures  may  be  attacked  at  one  and  the  same 
time;  its  usual  seat,  however,  is  the  scalp.  The  disease  begins 
by  the  development  of  one  or  of  several  pin-head  sized,  pale- 
yellow  crusts,  seated  about  the  hair-follicles.  In  about  a  fort- 
night these  crusts  have  increased  in  size  and  are  umbilicated, 
favus  cups,  circumscribed,  circular  in  form,  friable,  and  very 
slightly  elevated  above  the  level  of  the  skin.  Ordinarily,  they 
are  of  a  pale-yellow  or  sulphur-yellow  color,  but  after  a  time, 
from  dust  and  other  matters,  they  become  brownish  or  greenish 
yellow  in  color.  The  number  of  crusts  varies  from  very  few 
to  immense  numbers.  The  usual  size  is  about  that  of  a 
split  pea.  In  tinea  favosa  pilaris  et  capitis  the  affection  is  often 
accompanied  by  pediculi,  while  swelling  of  the  glands  of  the 
neck  and  small  abscesses  upon  the  scalp  are  not  uncommon. 
The  hairs  become  lusterless,  opaque,  brittle,  and  at  times 
split  longitudinally,  and  from  atrophy  of  the  follicles  and 
sebaceous  glands  and  scarring,  permanent  baldness  may  result. 

The  lesions  have  a  peculiar  odor,  resembling  that  of  mice,  or 
of  musty,  stale  straw. 


796  TINEA  FAVOSA. 

In  tinea  favosa  unguium  the  nails  become  thickened,  yellow, 
opaque,  and  brittle. 

Diagnosis. — The  distinctive  features  of  this  disease  that  will 
serve  to  differentiate  it  from  other  affections  of  the  scalp  are  its 
history,  long  duration,  the  sulphur-yellow,  umbilicated,  crusts, 
the  peculiar  odor,  the  atrophic  scarring,  and  the  presence  of  the 
fungus  which  may  be  readily  detected  by  microscopic  examina- 
tion. 

Prognosis. — Tinea  favosa  of  the  epidermis  readily  responds 
to  treatment.  Tinea  favosa  pilaris  is  more  obstinate,  and  if 
of  long  duration,  may  result  in  baldness. 

Treatment. — Many  of  the  patients  are  in  comparatively  poor 
health  and  require  general  tonic  treatment.  Attention  to  per- 
sonal hygiene  and  cleanliness  should  not  be  neglected.  The 
local  treatment  is  of  great  importance  and  consists  essentially 
in  depilation  and  the  application  of  parasiticides.  The  hair 
should  be  cut  off  as  short  as  possible,  the  crusts  removed  by  the 
use  of  oil,  or  soap  and  hot  water,  or  poultices,  again  well  oiled, 
and  the  hairs  removed  by  means  of  broad-bladed  forceps,  a 
few  hairs  being  removed  at  a  time  and  only  a  small  surface 
cleared  at  each  sitting,  after  which  the  following  lotion  is  to  be 
thoroughly  applied: 

I^.      Hydrarg.  chlorid.  corrosiv.  gr.  v  to  x     o .  3  to  o .  6  gm. 

Ammonii  chlorid 3ss  2  .  .    gm. 

Misturae  amygdalae  amar.    f  Biv  120,  c.c. 

M.S. — Apply  thoroughly  (Bulkley). 

Stelwagon  employs  the  following: 

I^.     Acid,  carbol 3i  4 .  gm. 

Ung.  picis.  liq., 

Ung.  hydrarg.  nitr at ..  aa    3ii  8.  gm. 

Ung.  sulphur oiv  16.  gm. 

M.    S. — Apply  locally. 

Owing  to  the  decomposition  likely  to  occur  in  this  preparation 
it  should  be  prepared  freshly  or  within  a  week  of  its  being 
employed. 

Other  parasiticides  may  also  be  employed,  the  keynote  to 


SCABIES.  797 

success  in  their  use  is  regular  vigorous  application  continued 
over  a  long  period.  No  case  should  be  discharged  until  the 
microscope  is  no  longer  able  to  reveal  the  fungus. 

When  the  nails  are  affected  they  should  be  scraped  in  addi- 
tion to  the  local  applications. 

SCABIES. 

Synonym. — The  itch. 

Definition. — A  contagious  animal  parasitic  disease  of  the  skin , 
due  to  the  acarus,  or  sar copies  scahiei;  characterized  by  the 
formation  of  cuniculi  (burrows),  papules,  vesicles,  pustules; 
followed  by  excoriations,  crusts,  and  general  cutaneous  inflam- 
mation, and  accompanied  by  itching. 

Causes. — The  essential  cause  is  the  animal  parasite,  acarus 
or  sarcoptes  scahiei.  The  affection  is  contagious  and  attacks 
individuals  at  all  ages  and  in  every  walk  of  life. 
It  may  be  contracted  by  direct  contact  with  in- 
fected persons  or  through  the  medium  of  bedclothes 
and  similar  articles.  It  is  most  frequent  where 
there  are  large  bodies  of  people  congregated 
together  under  unhygienic  conditions,  as  in  camps, 
barracks,  ships,  tenement  houses,  etc. 

Pathology. — Scabies   is  an  inflammation  of  the 
skin    with    the    development   of   papules,  vesicles,    coptes  ^Scabiei 
pustules,  excoriations,  and  subsequent  crusting,  the    caFfnagnoii^^' 
result  of  the  ravages  of  the  animal  parasite,  together 
with  the  irritation  produced  by  the  scratching  of  the  patient. 

The  parasite  acarus,  or  sarcoptes  scahiei,  is  a  minute  creature, 
barely  visible  to  the  naked  eye,  appearing  as  a  yellowish-white, 
rounded  body.  The  female  is  the  most  commonly  encountered; 
the  males  are  said  to  take  no  part  in  causing  the  affection  and 
are  rarely  seen.  They  are  said  to  die  in  about  a  week  after 
copulation  with  the  female.  The  female  finds  her  way  boring 
through  the  horny  layer  into  the  mucous  layer  of  the  epidermis, 
and,  being  impregnated,  begins  at  once  laying  her  eggs  and  at 
the  same  time  making  her  burrow.     A  variable  number  of  eggs 


798  SCABIES. 

is   deposited,  usually   about   a  dozen,  after  which  she  perishes 
in  the  skin.     The  ova  hatch  out  in  six  or  ten  days. 

Symptoms. — The  eruption  of  scabies  is  an  artificial  dermatitis 
or  eczema,  according  to  the  amount  of  irritation  produced  by 
the  presence  of  the  parasite  and  the  traumatism  resulting  from 
the  severe  scratching  of  the  patient. 

Immediately  upon  the  arrival  of  the  itch-mite  upon  the  skin  it 
begins  its  work  of  burrowing,  and  very  soon  a  burrow,  or 
cuniculus ,  is  formed,  in  which  the  eggs  are  deposited,  and  which 
also  becomes  the  habitat  of  the  female  during  the  remainder  of 
her  life.  The  ova  are  hatched  in  about  one  week  after  their 
deposit,  and  at  once  begin  to  care  for  themselves  and  to  burrow, 
resulting  in  the  formation  of  as  many  additional  cuniculi  as 
there  are  active  female  mites.  It  is  the  presence  of  these  bur- 
rowing parasites  that  constitutes  the  irritation  resulting  in 
the  inflammation  of  the  skin,  characterized  by  the  formation 
of  minute  papules,  vesicles,  and  pustules,  with  more  or  less 
inflammatory  induration.  Add  to  these  the  excoriations, 
scratch  marks,  fissures,  torn  vesicles,  and  pustules  with  yellow 
and  bloody  crusts,  caused  by  the  scratching,  and  a  picture  of 
the  fully  developed  disease  is  seen. 

The  hurrow,  or  cuniculus ,  as  it  is  termed,  is  formed  by  the  mite 
entering  and  making  its  way  beneath  the  horny  layer  of  the  epi- 
dermis, which  is  raised,  very  much  as  a  mole  undermines  the 
ground.  It  occurs  as  a  slight  linear  elevation  of  the  epidermis 
varying  from  a  half  a  line  to  four  or  five  lines  in  length,  and 
having  an  irregular  or  tortuous  course.  Its  color  is  whitish 
or  yellowish,  speckled  here  and  there  with  dark  dots.  At  either 
end  the  cuniculus  terminates  as  darkish  points,  the  more  promi- 
nent of  which  represents  the  parasite. 

The  papules  are  the  first  inflammatory  lesion ;  they  are  numer- 
ous and  of  small  size,  and  may  be  the  extent  of  the  disease. 
The  vesicles  are  the  next  stage,  varying  in  size  and  number, 
having  an  inflamed  base,  sometimes  presenting  cuniculi  upon 
their  summits.  The  pustules  represent  the  completion  of  the 
inflammatory  action,  their  size  and  number  varying  with  the 
severity  of  the  irritation. 


SCABIES.  799 

The  intense  itching,  which  is  worse  at  night,  results  in  excoria- 
tions, torn  papules,  vesicles,  and  pustules,  followed  by  crustings, 
which  after  a  time  disguise  the  characteristic  lesions.  The 
regions  of  the  body  attacked  by  the  parasite  are  the  hands, 
especially  the  sides  of  the  fingers  and  the  folds  where  they  join 
the  hands.  After  a  time  the  wrists,  penis,  and  mammae,  and 
around  about  and  upon  the  nipples,  are  invaded.  The  resultant 
multiform  eruption  is  usually  found  in  the  various  flexor  regions 
of  the  body,  inner  sides  of  the  thighs,  and  the  buttocks,  but 
may  be  general.  The  face  is  free  from  the  disease  except  occa- 
sionally in  nursing  infants.  In  very  clean  persons,  or  those 
having  their  hands  constantly  in  water,  there  may  be  no  burrows 
or  other  lesions  on  the  hands. 

Diagnosis. — The  presence  of  the  itch-mite  and  its  burrows  is 
pathognomonic.  A  multiform  eruption  most  marked  in  the 
flexor  regions  with  intense  itching,  worse  at  night,  and  a  history 
of  contagion  are  also  diagnostic  of  the  disease.  Frequently  the 
burrows  are  removed  by  scratching  and  a  careful  search  fails 
to  detect  any  of  them. 

Prognosis. — The  disease  never  tends  toward  spontaneous  cure. 
When  severe,  a  diffuse  eczema  may  be  engrafted  on  the  original 
condition.  Under  appropriate  treatment  response  is  prompt 
and  cure  is  rapid. 

Treatment. — In  every  instance,  all  members  of  the  household 
having  the  affection  should  be  treated  at  the  same  time.  The  bed- 
clothing  and  underclothing  of  infected  individuals  should  be 
sterilized.  Patients  under  treatment  should  sleep  alone  for 
obvious  reasons.  The  treatment  should  be  directed  first  to- 
ward the  scabies,  after  which  the  attendant  dermatitis  should 
receive  attention.  The  following  plan  of  treatment  is  very 
satisfactory:     An  ointment  such  as— 

I^.      Sulph.  precip 5i  4  •  gi^- 

Petrolat gi  32.  gm, 

M.  S. — Apply  locally  at  night. 

should  be  ajjplied  all  over  the  body  from  the  neck  to  the  soles  of 
the  feet  for  four  nights,  after  which  a  hot  bath  is  taken  and  the 


8oo 


SCABIES. 


bedclothes  and  underclothes  are  changed.  The  treatment  is 
then  withheld  for  an  equal  period  to  allow  the  irritation  to  sub- 
side. If  after  this  period  elapses  the  generalized  itching  re- 
turns, the  ointment  is  again  applied  in  a  similar  manner  for 
three  or  four  days.  At  the  end  of  this  time,  only  a  few  localized 
areas  of  itching  will  remain,  which  will  also  disappear  with  the 
application  of  a  weak  carbolic-acid  lotion  or  ointment  (gr.  v  to 
X  to  the  ounce). 

Another  valuable  method  of  treatment  consists  in  the  patient 
first  washing  himself  thoroughly  with  soft  soap  and  water,  after 
which  a  warm  bath  is  taken.  Tincture  of  benzoin  or  one  of  the 
following  is  then  applied  all  over  the  body  twice  daily  except 
the  head  and  face: 


I^.      Sulph.  precip., 

Betanaphthol aa  5ss  2  .  gm 

Petrolat 5i  32  .  gm 

M.  S. — Apply  locally. 

I^.      Styracis  liquid f  5ii  8  .  gm 

Ung.  sulphur 5ii   to  iv  8 .  to  16.  gm 

Petrolat •.  .  q.  s.  ad  Si                 32  .  gmi 

M.  S. — Apply  after  washing  (Bulkley). 

I^.      Sulph.  precip 5i  4.  gm 

Balsam.  Peruvian! 5ss  2  .  gm 

Adipis gi  32  .  gm 

M.  S. — For  children  (Duhring). 

I^.      Creolin gr.  v  .32  gm 

Petrolat. gi  32 .       gm 

M.  S. — Apply  locally. 


In  children,  the  strength  of  all  remedies  employed  for  this 
purpose  should  be  reduced  to  prevent  undue  irritation.  Styrax 
and  balsam  of  Peru  are  most  useful  in  infantile  cases.  In 
using  betanaphthol,  its  stinging  properties  when  first  applied 
should  be  borne  in  mind.  Apart  from  this,  it  is  perhaps  the 
most  elegant  of  all  these  preparations.  Care  should  always 
be  taken  not  to  continue  the  treatment  for  too  long  a  period  at 
a  time. 


PEDICULOSIS. 


80 1 


PEDICULOSIS. 

Synonyms. — Phthiriasis ;  lousiness. 

Definition. — A  contagious,  animal  parasitic  disease  of  the 
head,  body,  or  pubes,  due  to  the  presence  of  pediculi  and  char- 
acterized by  the  wounds  inflicted  .by  the  parasite,  together  with 
excoriations  and  scratch  marks. 

Varieties.- — Pediculosis  capitis;  pediculosis  corporis;  pediculosis 
pubis. 

Patjiology. — The  lesion  produced  by  the  presence  of  the 
pediculi  is  a  minute  hemorrhage,  caused  by  the  parasite  in- 
serting its  sucking  apparatus,  or,  as  it  is  termed,  its  haustellum, 
into  a  follicle,  and  obtaining  blood  by  a  process  of  sucking,  and 
not  by  biting  as  is  generally  supposed.  The  presence  of  the 
parasite  in  any  great  numbers  brings  about  a  peculiar  irritable 
state  of  the  skin,  which  gives  rise  to  an  irresistible  desire  to 
scratch,  as  a  consequence  of  which  the 
surface   is   markedly  excoriated. 

Symptoms. — The  symptoms  which  arise 
from  the  presence  of  the  parasite  in  differ- 
ent localities  are  somewhat  different,  and 
call  for  separate  consideration. 

Pediculosis  Capitis. — This  variety  is 
caused  by  the  presence  of  the  pediculus 
capitis,  or  head-louse.  The  ova,  or  nits, 
are  readily  recognized  at  a  distance.  Their 
favorite  seat  is  the  occipital  region,  either 
upon  the  surface  of  the  scalp  or  upon  the  hair.  Their  presence 
gives  rise  to  considerable  irritation,  itching,  and  consequent 
scratching,  resulting  in  the  wounding  of  the  scalp,  with  oozing  of 
a  serous  or  purulent  fluid  mixed  with  blood,  which  soon  mats 
the  hair  and  forms  into  crusts.  In  those  predisposed  to  eczema 
the  presence  of  the  parasite  will  give  rise  to  that  condition. 

Pediculosis  Corporis. — This  variety  of  the  pediculosis  is  caused 
by  the  presence  of  the  pediculus  corporis,  or  body-louse,  or  more 
properly  termed  the  pediculus  vestimenti,  or  clothes-louse.  Its 
color,  when  devoid  of  blood,  is  dirty-white  or  grayish,  with  a 

51 


Fig.  62. — Pediculus 
Capitis  and  egg.  {Greene's 
Medical  Diagnosis.) 


8o2  PEDICULOSIS. 

dark  line  around  the  margin  of  its  abdomen.  Its  habitat  is  the 
clothing  covering  the  general  surface,  remaining  upon  the  skin 
only  long  enough  to  obtain  sustenance.  The  ova  are  usually- 
deposited  in  the  seams  of  the  clothing,  the  lice  being 
hatched  within  the  week.  Occasionally  a  few  of  the  pediculi 
may  be  observed  crawling  about  the  surface,  or  in  the  act  of 
drawing  blood.  As  they  move  over  the  surface  they  give  rise 
to  an  intensely  disagreeable  itching  sensation,  to  relieve  which 
the  patient  scratches,  which  in  turn  gives  rise  to  the  char- 
acteristics lesions  of  the  affection. 

The  lesions  are  numerous.  The  scratch  marks  are  scattered 
here  and  there,  either  long  and  streaked,  in  other  places  short 
and  jagged,  the  excoriations  and  blood-crusts  varying  in  size 
from  a  pin-head  to  a  split  pea  or  even  larger,  with  irregularly 
shaped  pustules.  In  addition  to  the  lesions  resulting  from  the 
scratching  are  seen  the  primary  lesions,  consisting  of  minute, 
reddish  puncta  with  slight  areolae,  the  points  at  which  the  para- 
site has  drawn  blood.  In  cases  of  long  standing  a  brownish 
pigmentation  of  the  whole  skin  may  result  from  the  long-con- 
tinued irritation  and  scratching.  The  favorite 
sites  of  the  lesions  are  the  back,  especially 
about  the  scapular  region,  the  chest,  abdomen, 
hips,  and  thighs.  Pediculosis  is  seen  most 
commonly  among  the  poorer  classes,  and  espe- 
cially the  middle-aged  and  elderly. 
uiu^s     "^P^bis^"  Pediculosis   Pubis. — This   variety  of   pedicu- 

Diaenos^s )  ^^^'^^^"^  losis  is  caused  by  the  presence  of  the  pediculus 
pubis,  or  crab-louse.  Although  having  its  seat 
of  predilection  about  the  pubes,  it  may  also  infest  the  axillae, 
sternal  region  in  the  male,  beard,  eyebrows,  and  even  the 
eyelashes. 

They  may  be  found  crawling  about  the  hairs,  but  more  com- 
monly hugging  the  surface  closely.  They  infest  adults  chiefly 
and  occasion  symptoms  similar  to  those  described  in  connection 
with  the  other  varieties.  They  are  usually  contracted  through 
sexual  intercourse,  although  occasionally  they  are  present  in 
cases  in  which  they  have  not  been  communicated  in  this  way, 


LENTIGO.  803 

and  in  which  no  explanation  as  to  the  mode  of  contagion  can 
be  suggested.     The  itching  varies  from  slight  to  severe. 

Diagnosis. — When  violent  itching  exists  in  any  case,  without 
a  well  defined  eruption,  the  possibility  of  the  presence  of  pedic- 
uli  should  always  be  entertained,  and  if  carefully  sought  after, 
are  usually  found. 

Prognosis. — Favorable,  if  the  treatment  be  thoroughly  carried 
out. 

Treatment.  Pediciilosis  Capitis. — The  most  effective  appli- 
cation to  this  variety  is  to  thoroughly  soak  the  head  two  or 
three  times  a  day  with  ordinary  petroleum  or  kerosene  oil  and 
keep  it  wrapped  in  a  cloth  for  twenty-four  hours.  At  the  end 
of  this  time  the  head  should  be  thoroughly  washed  with  soft  soap 
and  hot  water,  dried,  and  saturated  with  the  official  ointment  of 
ammoniated  mercury.  If  required,  this  entire  procedure  may 
be  repeated,  but  usually  any  pediculi  escaping  the  petroleum 
are  destroyed  by  the  ointment. 

Pediculosis  Corporis. — In  this  variety  the  habitat  of  the 
parasite  being  the  clothes,  they  must  be  boiled  or  baked  at  a 
temperature  sufficiently  high  to  destroy  their  life.  After  this 
the  clothing  should  be  changed  every  day  or  two,  carefully 
inspected,  and  if  pediculi  are  seen,  they  must  again  be  baked 
or  boiled.  For  the  irritation,  itching,  and  excoriations,  mild 
alkaline  baths  or  lotions  of  carbolic  acid  are  sufficient. 

Pediculosis  Pubis. — The  parts  should  be  washed  twice  daily 
with  soft  soap  and  water,  after  which  the  thorough  application 
of  tincture  of  cocculus  indicus  (fish  berries),  full  strength  or 
diluted,  dried,  and  saturated  with  the  officinal  ointment  of 
ammoniated  mercury,  or  mercurial  ointment  (blue  ointment), 
will  be  effectual. 

HYPERTROPHIES  OF  THE  SKIN. 
LENTIGO. 

Synonyms. — Freckles. 

Definition. — A  pigmentary  deposit  of  the  skin,  characterized 
by  irregularly  shaped,  pin-head  or  pea-sized,  yellowish,  brown- 


804  CHLOASMA. 

ish,  or  blackish  spots  occurring  for  the  most  part  about  the  face 
and. back  of  the  hands. 

Cause. — In  the  majority  of  instances  exposure  to  the  sun  is 
the  exciting  cause. 

Pathology. — In  the  anatomic  structure  freckles  consist  of  a 
circumscribed,  increased  amount  of  normal  pigment,  differing 
from  chloasma  only  in  the  peculiar  form  and  size  of  the  deposit. 

Symptoms. — The  number  of  "freckles"  varies  from  a  very 
few  to  immense  numbers.  They  occur  as  brownish  or  yellowish- 
brown,  small,  roundish,  irregular  spots,  most  commonly  upon 
the  face  and  hands.  Rarely  the  number  is  very  great,  and 
they  give  to  the  skin  an  uncleanly  appearance.  They  are  apt 
to  occur  at  all  ages,  but  rarely  before  the  third  year.  They 
are    unattended    with   itching   or   other   subjective   symptoms. 

Prognosis. — Usually  favorable.  Their  course,  when  left  to 
themselves,  is  chronic,  lasting  for  years  or  a  life-time.  They 
ordinarily  appear  in  the  summer,  fading  away  as  cold  weather 
approaches,  to  return  the  following  summer. 

Treatment. — The  following  application  has  usually  been 
successful : 

I^.      Hydrargyri      chlor,      cor- 

rosiv gr.  iij  0.2  gm. 

Acid,  hydrochlorici  dil. .  .    f5j  4.     c.c. 

Alcoholis f  5j  30.     c.c. 

Glycerini f  5 ss  15.     c.c. 

Aquae  rosae q.  s.  ad  f  5iv  ad  120.     c.c. 

M.  S. — Apply  at  bedtime,  and  remove  with  soap  and  water 
in  the  morning. 

CHLOASMA. 

Synonyms. — Liver  spots ;  moth. 

Definition. — A  pigmentary  disturbance  of  the  skin,  character- 
ized by  variously  sized  and  shaped,  more  or  less  defined,  smooth 
patches,  of  a  yellowish,  brownish,  or  blackish  color. 

Cause. — The    affection   may  be   idiopathic   or  symptomatic. 

Idiopathic  chloasma  results  from  the  irritation  of  long-con- 
tinued scratching,  such  as  occurs  in  severe  eczema  or  pediculosis, 


CHLOASMA.  805 

the  appli(iation  of  blisters  and  sinapisins,  heat,  the  direct  rays 
of  the  sun,   and  various  medicinal  and  chemical  substances. 

Symptomatic  chloasma  occurs  in  connection  with  cancer, 
malaria,  tuberculosis,  disease  of  the  suprarenal  capsule  (Addison's 
disease),  disease  of  the  uterus,  pregnancy  (chloasma  uterinum), 
neurotic  disturbances,  dementia,  anemia,  and  chlorosis. 

Pathology. — The  affection  consists  of  an  increased  deposit 
of  the  normal  pigment  in  the  mucous  layer  of  the  epidermis. 
The  deposition  of  the  additional  pigment  is  the  result  of  a 
nervous  derangement,   possibly  of  the  trophic  system. 

Symptoms. — Chloasma  is  simply  a  discoloration  of  the  skin, 
unattended  by  any  alteration  of  the  surface.  The  patches 
vary  in  size  and  shape;  they  may  be  as  small  as  a  coin  or  as 
large  as  the  hand,  or  much  larger,  even  to  a  universal  discolora- 
tion of  the  entire  surface,  and  they  may  be  roundish  or  irregular 
in  outline.  The  usual  color  is  yellowish,  brownish,  or  muddy, 
or  even  blackish  {melasma  melano-derma) . 

In  Addison's  disease,  of  a  typical  character,  the  coloration 
is  brownish,  with  an  olive-greenish  or  bronze  tint,  and  is  general, 
although,  as  a  rule,  especially  pronounced  upon  regions  having 
a  disposition  to  normal  increase  of  pigment,  as  the  face,  backs 
of  the  hands,  axilte,  areola  of  the  nipples,  and  the  genital  organs; 
the  hair,  also,  may  become  darkened. 

In  argyria,  or  discoloration  of  the  skin  resulting  from  the  in- 
ternal use  of  nitrate  of  silver  over  a  long  period,  the  color  is  a 
bluish  gray,  slate,  bronze,  or  blackish,  varying  as  to  the  shade. 
It  occurs  over  the  surface  generally,  but  is  more  pronounced 
upon  parts  exposed,  as  the  face  and  hands. 

Chloasma  uterinum,  occurs  most  frequently  between  the  ages 
of  twenty-five  and  fifty,  seldom  after  the  menopause,  and  is 
caused,  in  the  greater  number  of  instances,  by  changes,  physio- 
logic and  pathologic,  which  take  place  in  connection  with  the 
uterus.  It  is  seen  in  the  married  and  single,  although  more 
common  in  the  former.  Pregnancy  is  the  most  frequent  cause, 
but  it  is  also  associated  with  either  dysmenorrhea,  chlorosis, 
anemia,  and  hysteria.  It  is  seen  in  the  mildest  degree  about  the 
eyelids,  especially  during  the  menstrual  epoch,  as  a  duskiness  or 


8o6  CHLOASMA. 

swarthiness  of  the  complexion,  either  lasting  a  few  days  or 
being  permanent.  As  usually  encountered,  however,  chloasma 
of  this  variety  consists  in  the  presence  of  one  or  several  patches, 
appearing  generally  about  the  forehead  or  other  parts  of  the 
face,  upon  the  trunk,  about  the  nipples,  and  upon  the  abdomen. 
Rarely  the  entire  face  is  covered  with  a  discoloration,  resembl- 
ing a  mask.  Cases  are  recorded  in  which  the  pigmentary  de- 
posit was  general,  resembling  Addison's  disease. 

Diagnosis. — Tinea  versicolor  and  chloasma  resemble  each 
other  in  the  color  of  the  patches,  but  otherwise  they  have  noth- 
ing in  common.  Tinea  versicolor  occurs  on  the  trunk,  while 
chloasma  occurs  upon  the  face  and  about  the  nipples,  and  in 
cases  the  result  of  pregnancy  about  the  umbilicus,  except  in 
those  comparatively  rare  instances  in  which  the  discoloration 
is  diffused.  The  patches  of  chloasma  are  smooth,  those  of 
tinea  versicolor  furfuraceous,  as  can  readily  be  demonstrated 
by  gently  scraping  the  discoloration  with  the  finger-nail.  The 
parasite  is  absent  in  chloasma. 

Prognosis. — The  outlook  is  favorable  except  in  cases  due  to 
the  prolonged  use  of  silver  nitrate,  Addison's  disease,  tuber- 
culosis, or  cancer. 

Treatment. — Except  when  due  to  organic  disease  or  silver 
deposits  in  the  skin,  the  pigmented  areas  may  be  temporarily 
removed  by  one  of  the  following: 

I^,     Hydrargyri  chloridi  cor- 

rosiv gr.  viiss  o.  5  gm. 

Zinci  sulphat oss  2  .     gm. 

Plumbi  acetatis 5ss  2  .     gm. 

Aquae fSiv  120.     c.c. 

M.  S. — Lotion.     Apply  morning  and  evening  (Hardy). 

Or— 

I^.     Hydrargyri  chloridi  cor- 

rosiv gr.  vj  0.4  gm. 

Acidi  acetici  dil f  5ij  8 .     c.c. 

Boracis gr.xl  2  .  6  gm. 

Aquae  rosae f  §iv  120.     c.c. 

M.  S. — Lotion.     Apply  twice  daily  (Bulkley). 


CALLOSITAS.  807 

I^.      Hydrarg.  ammoniat 3j  4.  gm. 

Bismuthi  subnit 5j  4  •  gm. 

Petrolat 5j  32  .  gm. 

M.   S. — Apply  frequently. 


CALLOSITAS. 

Synonyms. — Tyloma;  callus;  callosity. 

Definition. — Callositas  consists  in  the  development  of  a  hard 
or  horny,  thickened  patch  of  skin,  variable  in  extent,  of  a 
grayish,  yellowish,  or  brownish  color,  and  unattended  by 
pain.      The  most  frequent  location  is  upon  the  hands  and  feet. 

Causes. — The  principal  cause,  is  local  pressure  or  friction,  as 
in  the  case  of  the  hands  of  the  mechanic,  the  effect  of  his  tools; 
or,  if  upon  the  foot,  the  result  of  ill-fitting  shoes  or  from  long 
marches.  Callosities  are  also  seen  upon  the  fingers  of  violin, 
banjo,  and  harp  players. 

Pathology. — Hypertrophy  of  the  horny  layer  of  the  skin. is 
oresent,  the  corium  remaining  normal.  The  cells  of  the  epi- 
dermis become  so  closely  packed  together  as  often  to  simulate 
horn-substance . 

Symptoms. — Callositas  consists  in  an  increase  in  the  thick- 
ness of  the  skin  of  the  affected  part,  presenting  a  firm,  dense, 
more  or  less  circumscribed  structure,  the  extent  of  hardness 
varying  considerably.  The  patch  of  hardness  is  generally 
about  the  size  of  a  coin,  roundish  in  shape,  and  somewhat 
elevated  above  the  surrounding  skin.  The  color  may  be  either 
grayish,  yelloiwish,  or  brownish. 

Callosities  are  usually  situated  upon  the  palms,  fingers,  soles, 
and  toes,  although  other  parts,  if  exposed  to  the  cause,  may  also 
be  the  seat.  At  times  great  pain  and  discomfort  are  experienced 
from  the  growth. 

Occasionally  calosities  are  complicated  by  hyperemia,  fissures, 
acute  inflammation,  abscess,  erysipelas,  and  serve  readily  as  foci 
for  such  cutaneous  diseases  as  eczem.a  and  psoriasis.  '  Their 
formation  and  development  is  always  slow  and  gradual.  If 
the  cause' be  removed,  the  prognosis  is  favorable. 


8o8  ■  CLAVUS. 

Treatment. — If  the  removal  of  the  callous  growth  be  desirable, 
the  part  should  be  repeatedly  soaked  in  warm  water,  or  a  poul- 
tice applied,  or  warmed  oil  kept  in  contact  by  compresses  of 
flannel,  which  will  soften  the  induration  and  permit  its  removal 
by  paring  or  scraping,  layer  by  layer,  with  a  sharp  knife. 
Success  has  been  obtained  from  the  use  of  a  plaster  of  india- 
rubber  containing  salicylic  acid.  Painting  with  diluted  tinc- 
ture of  iodin  once  daily  is  often  serviceable. 

CLAVUS. 

Synonym. — Corn. 

Definition. — A  corn  is  a  small,  circumscribed,  usually  fiat, 
deep-seated  hypertrophy  of  the  epidermis,  having  a  horny  feel, 
projecting  slightly  from  the  skin,  painful  upon  pressure,  and 
situated  for  the  most  part  about  the  toes. 

Cause. — Continual  pressure  or  friction,  usually  from  ill- 
fitting  or  tight  boots  or  shoes. 

Pathology. — A  clavus  consists  of  a  circumscribed,  excessive 
hypertrophy  of  the  epidermis,  of  the  same  character  as  occurs  in 
callosity,  and  of  a  central  portion — the  core.  The  core  extends 
deeply  into  the  tissues,  in  the  shape  of  an  inverted  cone,  the 
base  of  the  cone  being  directed  outward  and  appearing  upon  the 
surface  as  a  roundish  elevation,  its  apex  resting  upon  the 
papillary  layer  of  the  corium.  The  core  of  a  clavus  consists 
of  a  whitish,  opaque,  firm,  tenacious  body,  composed  of  epider- 
mic cells,  arranged  in  concentric  laminae. 

The  pain  attending  the  presence  of  corns  results  from  pres- 
sure upon  the  true  skin  by  the  hard  core,  causing  irritation  of  the 
nerve -filaments  of  the  papillae. 

Corns  existing  between  two  toes  are  constantly  bathed  with 
the  moisture  of  the  part,  which  macerates  and  softens  the  forma- 
tion, which  thus  receives  the  name  of  soft  corn,  in  contradis- 
tinction to  the  hard  com. 

Symptoms. — Until  the  growth  attains  a  considerable  size  no 
discomfort,  as  a  rule,  is  felt.  After,  however,  its  depth  has 
reached  the  true  skin,  pain  of  an  intermittent  character,  aggra- 


ICHTHYOSIS.  809 

vated  by  pressure,  is  the  chief  symptom.  Corns  are  often 
weather  sensitive,  being  unusually  painful  before,  during,  or 
after  the  occurrence  of  storms,  and  should,  therefore,  not  be 
confounded  with  gouty  or  rheumatic  deposits  below  the  skin. 

Treatment. — If  freedom  from  these  annoying  formations  be 
desired,  a  properly  fitting  foot-covering  must  be  worn.  The 
pressure  which  results  in  the  severe  pain  is  limited  by  the  use 
of  the  ringed  protective  plasters  in  common  use. 

To  remove  the  corn,  soaking  with  hot  water,  or  a  poultice 
kept  in  contact  over  night,  will  soften  the  part  and  permit  of  its 
ready  removal  with  the  knife. 

The  following  application  will  usually  remove  the  "corn": 

I^.     Acidi  salicylici oiss  6.     gm. 

Ext.  cannab.  indicae gr-x  0.6  gm. 

CoUodii f  oj  30.     c.c. 

M.  S. — To  be  painted  over  the  corn  at   night  and  scraped 
ofif  in  the  morning. 

For  soft  corns,  the  application  of  silver  nitrate  in  solid  stick 
form  is  highly  spoken  of,  to  be  used  after  the  growth  has  been 
sufficiently  softened. 

ICHTHYOSIS. 

Synonyms. — Ichthyosis  vera;  fish-skin  disease. 

Definition.— Ichthyosis  is  a  congenital,  chronic  deformity  or 
hypertrophic  disease  of  the  skin,  characterized  by  dryness, 
harshness,  or  general  scaliness  of  the  skin,  or  in  the  outgrowth 
of  larger  masses  of  a  corneous  consistency. 

Varieties. — Ichthyosis  simplex;  ichthyosis  hystrix. 

Cause. — It  is  to  be  regarded  as  an  affection  which  is  bom  with 
the  individual,  although  it  does  not  usually  manifest  itself  until 
after  the  first  or  second  year  of  life.     It  is  often  hereditary. 

Pathology. — "  The  diseased  or,  better,  deformed  skin  is  found 
microscopically  to  be  hypertrophied  in  various  degrees,  accord- 
ing to  the  development  of  the  malady;  the  proliferation  of  its 
elements  occurring  in  the  connective  tissue,   papillae,   stratum 


8lO  ICHTHYOSIS. 

comeum,  and  blood-vessels.  In  well-marked  cases  of  ichthyo- 
sis hystrix  the  elongated  papillae  are  surrounded  by  dense  cones 
of  the  horny  layer  of  the  epidermis,  more  or  less  concentrically 
disposed,  with  sclerosis  of  the  connective  tissue  and  ?  relatively 
unchanged  rete.  In  this  last  particular  the  dense  plaque  of 
ichthyosis  differs  in  texture  from  the  wart"  (Hyde). 

Symptoms. — Ichthyosis  displays  wide  variation  in  its  symp- 
toms. In  one  individual  it  amounts  to  slight  inconvenience, 
while  in  another  it  may  manifest  itself  in  so  pronounced  a 
manner  as  to  be  the  source  of  great  deformity  and  discomfort. 
The  two  varieties  named  represent  merely  accentuated  types 
of  the  disorder,  rare  in  its  fullest  development,  and,  in  the 
slightest,  much  more  common  than  is  generally  believed. 

A  simple  dryness  and  harshness  of  the  skin,  with  only  slight 
furfuraceous  exfoliation,  is  termed  xeroderma. 

Ichthyosis  simplex  is  the  more  common  variety,  consisting 
of  a  harsh,  dry  condition  of  the  whole  surface,'  accompanied 
by  the  production  of  variously  sized  and  shaped  reticulated 
scales,  either  small,  thin,  and  furfuraceous,  like  bran,  or  large 
and  thick,  resembling  fish-scales.  Upon  the  extremities,  the 
scales  usually  form  diamond-shaped  or  polygonal  plates,  separ- 
ated from  one  another  by  furrows  or  lines  which  extend  down  to 
the  normal  skin.  In  color,  the  scales  are  either  whitish,  gray- 
ish, or  yellowish,  and  often  have  a  silvery  or  glistening  appear- 
ance. Rarely  the  color  is  olive-green  or  blackish  {ichthyosis 
nigricans) .  The  amount  of  scaling  depends  upon  the  age  of  the 
patient  and  the  duration  and  severity  of  the  disease. 

Ichthyosis  Hystrix.- — With  or  without  the  development  of 
the  above  variety,  in  this  the  hypertrophy  of  the  skin  may  occur 
in  circumscribed  patches  or  large  areas,  consisting  of  irregularly 
shaped  verrucous,  corneous,  corrugated,  wrinkled,  or  rugous 
masses,  usually  darker  in  color  than  those  of  the  simple  variety. 
They  may  occur  upon  the  arms,  as  solid,  warty  patches,  or 
upon  the  back,  in  the  form  of  elongated,  linear  patches.  They 
may  constitute  roughened,  corrugated,  papillary  growths,  or  un- 
even, homy,  blunt,  or  pointed,  spinous,  warty  formations.  In  the 
latter  case  the  elevations  may  reach  several  lines  or  more,  and 


ICHTHYOSIS.  8ll 

stand  out  from  the  skin  like  quills  upon  the  back  of  a  porcupine 
— hence  the  name  hystrix.  The  amount  and  extent  of  the 
hypertrophy  varies;  the  older  the  patient,  the  more  highly 
developed  it  will  usually  be. 

Course. — Ichthyosis  simplex  may  involve  the  entire  surface 
uniformly  or  appear  more  marked  on  the  extremities,  from  the 
hips  to  the  ankles  and  the  arms  and  forearms.  The  affection 
is  always  worse  in  winter  than  in  summer,  the  increased  ac- 
tivity of  the  sweat  glands  at  this  season  producing  the  most 
beneficial  results.  The  course  of  the  'affection  is  essentially 
chronic,  continuing  throughout  life,  now  better,  now  worse. 
Slight  itching  usually  occurs. 

Diagnosis. — The  characteristics  of  the  affection  are  so  pe- 
culiar that  an  error  in  diagnosis  is  hardly  possible.  It  is  to  be 
distinguished  from  the  inflammatory  affections  of  the  skin 
which  terminate  in  desquamation  by  the  absence  of  any  history 
of  inflammation.  ^ 

Prognosis. — While  much  can  be  done  to  alleviate  the  affec- 
tion, the  prognosis  is  unfavorable  as  regards  permanent  relief. 

Treatment. — Local  measures  are  alone  of  value  for  ichthyosis. 
The  maceration  of  the  accumulated  masses  of  epithelial  hyper- 
trophy is  accomplished  by  water-baths,  either  simple  or  medi- 
cated. The  relief  thus  afforded  the  patient,  while  temporary, 
is  comforting.  Vapor  and  alkaline  baths  are  also  serviceable. 
Another  valuable  agent  is  soft  soap  in  conjunction  with  baths, 
or  alone,  as  a  discutient.  For  severe  cases,  "  a  sufficient 
quantity  is  to  be  rubbed  into  the  skin  twice  daily  for  four  or 
six  days,  during  which  period  the  patient  is  to  refrain  from 
bathing.  A  bath  is  first  to  be  taken  four  or  five  days  after 
the  last  rubbing,  when,  in  fact,  the  epidermis  has  begun  to  peel 
off;  afterward  inunction  with  a  simple  ointment  is  to  be  applied 
in  order  to  prevent  fissuring  of  the  new  skin." 

The  following  is  a  useful  formula: 

I^.     Adipis  benzoat oj  32 .     gm. 

Glycerini n^xl  2  .  6  c.c. 

Petrolat §ss  16.     gm. 

M.  S. — Apply  daily,  after  washing  or  bathing. 


8l2  VERRUCA. 

Or— 

I^.     Potassii  iodidi gr.xx  1.3  gm. 

.Olei  bubuli f  5ss  15.     c.c. 

Adipis §ss  16.     gm. 

Glycerini f  oij  8  .     c.c. 

M.  S. — Apply  after  bathing  (Milton). 

VERRUCA. 

Synonym. — Wart. 

Definition. — A  wart  consists  of  a  circumscribed  hypertrophy 
of  the  papillary  layer,  with  more  or  less  epidermal  accumulation, 
characterized  by  the  appearance  of  a  hard  or  soft,  rounded,  fiat, 
or  acuminated  formation,  of  variable  size. 

Varieties. — The  following  varieties  have  chiefly  a  descriptive 
value:  verruca  vulgaris;  verruca  plana;  verruca  filiformis;  ver- 
ruca digitata;  verruca  acuminata. 

Cause. — Obscure.  Irritation,  uncleanliness,  and  microor- 
ganisms are  responsible  for  some  forms. 

Pathology. — While  the  anatomy  of  warts  differs  somewhat 
according  to  their  variety,  in  all  forms  there  exists  as  a  basis 
of  their  formation  a  connective-tissue  growth  from  which  the 
papillary  hypertrophy  takes  place.  The  interior  of  the  growth 
is  supplied  by  one  or  more  vascular  loops,  from  which  their 
vitality  is  obtained. 

Symptoms. — Verruca  vulgaris,  or  the  ordinary  wart  commonly 
seen  on  the  hands,  consists  of  a  small,  circumscribed,  elevated 
growth  having  a  broad  base  seated  securely  upon  the  skin. 
Their  consistency  is  either  soft  or  firm,  the  surface  smooth  or 
rough,  and  the  color  that  of  the  surrounding  skin,  or  yellowish, 
brownish,  or  even  blackish.  They  may  develop  upon  any  region 
of  the  body  but  are  most  commonly  seen  upon  the  hands  and 
fingers. 

Verruca  plana  differs  from  the  vulgaris  in  being  fiat  and 
broad  in  form,  and  but  slightly  raised  above  the  level  of  the 
surrounding  skin.  Their  most  common  location  is  either  on 
the  back  or  forehead. 


VERRUCA.  *  813 

Verruca  filiformis  assumes  the  shape  of  a  minute,  thin,  coni- 
cal, or  thread-like  formation,  about  1/8  inch  in  length.  The 
most  frequent  location  is  the  face,  eyelids,  and  neck. 

Verruca  digitata  consists  of  a  slightly  elevated,  broad  forma- 
tion, about  the  size  of  a  split  pea,  and  marked  by  a  number  of 
digitations  coming  from  its  border,  giving  an  appearance,  in 
marked  cases,  resembling  a  crab.  Their  most  frequent  site  is 
upon  the  scalp. 

Verruca  acuminata,  known  also  as  the  pointed  wart,  the  moist 
wart,  the  pointed  condyloma,  cauliflower  excrescence,  and 
venereal  wart,  consists  of  one  or  more  groups  of  irregularly 
shaped  elevations,  often  so  closely  packed  together  as  to  form 
a  more  or  less  solid  mass  of  vegetations  (verrucce  vegetantes). 
Their  color  depends  somewhat  upon  the  degree  of  vascularity, 
varying  from  a  pinkish,  bright-red  to  a  purple  color.  They 
occur,  for  the  most  part,  about  the  genitalia  of  either  sex. 
Upon  the  penis  they  usually  spring  from  the  glans  and  the 
inner  surface  of  the  prepuce.  From  the  inner  surface  of  the 
labia  and  from  the  vagina  in  the  female.  They  are  also  seen 
about  the  anus,  mouth,  axillae,  umbilicus,  and  toes.  They 
may  be  either  moist  or  dry,  according  to  their  location. 
About  the  genitalia,  a  yellowish,  puriform  secretion  usually 
covers  their  surface,  due  to  friction  and  maceration,  which, 
owing  to  the  heat  of  the  parts,  rapidly  decomposes,  produc- 
ing a  highly  offensive,  penetrating,  and  disgusting  odor. 
Their  size  varies  from  that  of  a  pea  to  that  of  an  almond, 
an  egg,  or  even  the  fist.  Their  development  is  rapid,  attain- 
ing considerable  size  in  a  few  weeks. 

Prognosis. — Favorable. 

Treatment. — For  the  smaller  warts,  excision  by  means  of  the 
knife  or  scissors  affords  the  most  satisfactory  results.  If  the 
growth  be  large,  and  likely  to  be  attended  with  considerable 
hemorrhage,  as  in  cases  of  condyloma  about  the  genitalia,  the 
galvanocaustic  wire  or  the  Paquelin  cautery  are  to  be  preferred. 
Transfixing  the  growth  in  several  directions  with  long  needles 
dipped  in  a  50  per  cent,  solution  of  chromic  acid  has  been  recom- 
mended.    The  local  application  of  caustics  such  as  acetic  acid. 


8i4  'molluscum  epitheliale. 

trichloracetic  acid,  nitric  acid,  nitrate  of  silver,  or  perchlorid 
of  iron  is  often  satisfactory.  Painting  of  the  growth  with  tinc- 
ture of  thuja  occidentalis  until  their  size  is  considerably  reduced 
and  then  snipping  them  off  with  scissors  is  also  a  very  efficient 
mode  of  treatment.     The  following  applications  are  of  value: 

I^.     Acidi  salicylici oss  2 .     gm. 

Ext.  cannab.  indicae. .  .    gr.  v  to  x     o  .  3  to  o  .  6  gm. 

Collodii f  oss   to  j    15  .  to  30  .     c.c. 

M.  S. — Apply  once  or  twice  daily. 
Or— 

I^.      Acidi  salicylici 

Acidi  borici aa  gr.  xv  aa  i  .     gm. 

Hydrargyri  chlor.   mitis.    gr.  x  0.6  gm. 

M.  S. — Sprinkle  over  twice  daily. 

MOLLUSCUM  EPITHELIALE. 

Synonyms. — Molluscum  contagiosum;   molluscum  sebaceum. 

Description. — An  infrequent  epithelial  affection  characterized 
by  the  formation  of  discrete,  pin-head  to  pea-sized,  wax-like, 
whitish  or  pinkish  elevations,  the  summits  of  which  are  flattened 
and  have  a  central  opening  through  which  a  cheesy  fluid  may 
be  squeezed.  It  occurs  usually  in  children  and  is  slightly  con- 
tagious. The  lesions  occur  with  greatest  frequency  on  the  eye- 
lids and  cheeks  but  may  occur  on  the  trunk.  They  grow  very 
slowly  and  often  disappear  spontaneously  by  a  process  of 
sloughing  but  leaving  behind  no  scar.  Excision  or  cauteriza- 
tion may  be  performed  for  their  removal.  Ointment  of  am- 
moniated  mercury  is  useful  in  slight  cases. 

COMEDO. 

Synonyms. — Acne    punctata    nigra;    blackheads    or    worms. 

Definition. — A  disorder  of  the  sebaceous  glands ;  characterized 
by  the  retention  in  the  excretory  ducts  of  an  inspissated 
secretion  which  is  visible  upon  the  surface  as  yellowish  or 
whitish  pin-point  and  pin-head-sized  elevations,  containing 
in  their  centers  blackish  points. 


COMEDO.  815 

Causes. — The  exact  etiology  is  unknown.  Among  the  causes 
assigned  are  anemia,  menstrual  disorders,  urethral  irritations, 
dyspepsia,  and  constipation.  Acne  vulgaris  is  often  associated 
with  this  condition. 

Pathology. — Comedo  is  an  affection  of  the  sebaceous  glands 
and  ducts,  consisting  of  an  accumulation  of  sebum  and  epithe- 
lial cells  in  the  glands  and  follicles,  dilating  the  ducts  to  such 
an  extent  as  to  produce  the  point  or  elevation  upon  the  surface. 
The  obstructed  gland  may  relieve  itself,  or  it  may  continue 
distending  until  a  papule  is  formed.  The  duct  sometimes 
contains  small  hairs,  and  also  the  microscopic  mite,  Demodex 
folliculorum — having  a  length  of  from  1/150  to  1/75  inch,  and 
breadth  of  about  1/500  inch — which  was  at  one  time  supposed 
to  be  the  cause  of  the  affection. 

Symptoms. — The  affection  is  observed  for  the  most  part  on 
the  face,  neck,  chest,  and  back.  Each  elevation  or  blackhead 
or   point   is   designated   a   comedo;   if   a   number,    comedones. 

Each  comedo  is  small,  varying  from  a  pin-point  to  a  pin- 
head  in  size,  having  a  brownish  or  blackish  appearance,  from 
the  dust  or  dirt  that  has  adhered  to  the  unctuous  surface.  If 
they  form  in  great  numbers  upon  the  face  they  are  disfiguring, 
giving  the  individual  the  appearance  of  having  had  minute  grains 
of  powder  implanted  in  the  skin.  There  are  no  evidences  of 
inflammation  unless  acne  is  associated,  but,  on  the  contrary, 
the  skin  has  a  dirty,  greasy,  unwashed  appearance. 

Diagnosis. — There  is  no  condition  resembling  comedo,  so 
that  its  recognition  is  easy,  unless  complicated  with  acne; 
but  even  then  the  inflammatory  appearance  of  acne  should 
prevent  error. 

Prognosis. — Favorable,  although  often  remarkably  obstinate. 

Treatment. — Derangement  of  any  of  the  functions  of  the 
body  should  be  corrected,  and  strict  attention  be  given  to  the 
rules  for  promoting  the  general  health. 

Local  measures  are  usually  sufflcient.  The  parts  should  be 
thoroughly  softened  by  bathing  with  soap  and  warm  water, 
when  the  comedones  are  removed  by  friction  with  a  Turkish 
towel,  pressure  between  the  thumb  nails,  or  by  means  of   the 


8l6  MILIUM. 

instrument  known  as  the  "comedo-extractor,"  and  their  return 
prevented  by  an  ointment  medicated  to  meet  the  indications 
with  either  sulphur,  alkaHes,  or  mercury. 

Shoemaker  recommends  the  following  formula: 

I^.     Thymol gr.  x  0.65  gm. 

Acidi  borici. oij  8 .        gm. 

Aquas  hamamel.   Virg. 

dest f  5iv  15.       c.c. 

Aquae  rosae f§j  30.       c.c. 

M.  S. — Mop  well  over  surface  once  or  twice  daily. 


MILIUM. 

Synonyms. ^Grutum;  acne  punctata  albida. 

Definition. — An  accumulation  of  sebum  in  the  sebaceous 
glands  that  are  minus  their  excretory  ducts,  characterized  by 
the  formation  of  small,  roundish,  whitish,  sebaceous,  non- 
inflammatory elevations,  situated  immediately  beneath  the 
epidermis. 

Cause. — The  origin  of  the  affection  is  not  understood. 

Pathology. — The  sebaceous  gland  is  distended  with  the 
sebum,  which  is  unable  to  escape,  owing  to  the  obliteration  of 
the  duct,  nor  can  the  contents  be  squeezed  out,  as  no  sign  of 
aperture  is  to  be  found,  the  formation  being  completely  enclosed. 
Rarely  the  retained  secretion  undergoes  a  metamorphosis  into 
hard,  calcareous,  stone-like  masses — sebaceous  concretions  or 
cutaneous  calculi. 

Symptoms. — Milia  may  occur  upon  any  portion  of  the  body; 
their  usual  seat,  however,  is  upon  the  face,  forehead,  and  about 
the  eyes.  They  form  gradually,  are  about  the  size  of  a  millet- 
seed,  of  a  whitish,  pearl,  or  yellowish  color,  hard,  and  of  a  rounded 
shape,  giving  the  sensation  to  the  touch  of  hard  bodies  em- 
bedded in  the  skin.  They  are  not  associated  with  inflammatory 
symptoms. 

Diagnosis. — Milium  and  comedo  are  somewhat  similar  in  ap- 
pearance ;  the  differences  are  that  in  milium  the  sebaceous  gland 
is  distended  without  an  opening,  while  in  comedo  the  duct  of 


SEBACEOUS    CYST.  817 

the  gland  is  always  patulous  upon  the  surface.  Milium  usually 
exists  singly,  the  skin  looking  normal;  while  comedo  is  more 
general,    the   surface   having  a   soiled   and   greasy   appearance. 

Prognosis. — Favorable. 

Treatment. — As  a  rule,  no  treatment  is  needed,  the  number 
being  few  and  their  presence  of  no  consequence. 

If  their  removal  be  desirable,  two  modes  suggest  themselves 
one,  to  open  the  cyst  with  a  fine-bladed  bistoury,  turning  the 
contents  out,  and  destroying  the  remaining  sac  by  the  applica- 
tion of  either  tincture  of  iodin  or  chromic  acid;  or  the  cyst 
may  be  destroyed  by  electrolysis. 

SEBACEOUS  CYST. 

Synonyms. — Wen;  sebaceous  tumor;  encysted  tumor;  ather- 
oma; steatoma. 

Definition. — A  distention  of  the  sebaceous  gland  and  duct, 
with  hypertrophy  of  the  walls,  forming  a  thick,  tough  sac  or 
cyst,  characterized  by  a  firm  or  soft,  more  or  less  rounded 
tumor,  having  its  seat  in  the  skin  or  subcutaneous  connective 
tissue. 

Cause. — Unknown. 

Symptoms. — The  development  of  wens  is  slow  and  insidious. 
The  localities  where  they  are  most  commonly  observed  are  the 
scalp  face,  back,  and  scrotum.  The  tumors  occur  singly  or  in 
numbers;  in  size  from  a  pea  to  a  walnut,  or  larger;  in  shape  either 
rounded,  flattened,  or  semiglobular ;  in  consistency  they  are 
either  hard  or  soft  and  doughy;  they  are  freely  movable  and 
painless. 

Treatment. — Excision,  with  careful  and  thorough  dissection 
of  the  cyst  is  the  only  satisfactory  mode  of  treatment. 

KERATOSIS  PILARIS. 

A  cutaneous  affection  characterized  by  pin-head  sized  pap- 
ules   situated    at    the    mouths   of   the   follicles   resulting   from 
epidermal    accumulations    or    hypertrophy.     The    lesions    are 
52 


8l8  HYPERTRICHOSIS. 

grayish,  whitish,  or  blackish  in  color  and  are  found  most  fre- 
quently on  the  extensor  surfaces  of  the  extremities.  The  skin 
is  dry  and  rough  but  there  is  no  itching.  Infrequent  bathing 
is  believed  to  be  the  most  common  cause.  Bathing  with  soft 
soap  and  alkaline  water,  followed  by  vigorous  friction,  and 
inunctions  of  petrolatum  constitute  the  treatment. 

HYPERTRICHOSIS. 

Synonyms.^ — Hirsuties;  hypertrophy  of  the  hair;  superfluous 
hair. 

Definition. — A  local  or  general  overgrowth  of  the  hair,  either 
in  normal  or  abnormal  situations.  When  the  growth  occurs 
upon  a  mole  it  constitutes  ncevus  pilosus.  The  cause  of  hyper- 
trichosis is  unknown.  Some  cases  apparently  arise  from  local 
irritation. 

Treatment. — Removal  of  the  hairs  by  means  of  electrolysis 
is  the  only  satisfactory  method  of  treatment.  Shaving,  extrac- 
tion, and  the  use  of  depilatories  are  only  of  temporary  value. 

ELEPHANTIASIS. 

Elephantiasis  is  the  hypertrophic  condition  of  the  skin  and 
underlying  tissue,  having  its  origin  in  lymphatic  obstruction 
and  characterized  by  edema,  enlargement,  thickening  of  the  skin, 
overgrowth  of  the  papillae,  and  pigmentation.  The  causal 
lymphatic  obstruction  may  be  due  to  tumors,  cicatrices,  ery- 
sipelas, and  the  filaria  sanguinis  hominis.  It  is  most  common  in 
the  tropics  and  is  most  often  observed  in  male  adults.  The 
structural  changes  incident  to  the  disease  are  hypertrophy  of 
the  entire  skin  and  subcutaneous  tissue,  edema  of  affected 
structures,  and  dilatation  of  the  blood-vessels  and  lymphatics 
with  inflammation  of  the  latter.  The  disease  usually  affects 
the  leg  and  foot  but  the  genitalia  may  be  attacked. 

The  early  stages  of  the  disease  consist  of  recurring  attacks  of 
an  erysipelatoid  inflammation.  Restoration  to  normal  is  never 
complete   and  with  each  succeeding  attack  the  part  becomes 


ATROPHIES    OF    THE    SKIN.  819 

larger.  In  a  well-marked  case,  the  enlargement  is  very  great 
and  the  skin  is  thickened,  pigmented,  fissured,  and  covered 
with  papillomatous  outgrowths.  The  affection  is  essentially- 
chronic  and  pain  is  absent  except  in  acute  exacerbations.  The 
fully  established  disease  is  incurable;  but  in  the  early  stages 
sedative  applications,  elastic  compression,  and  mercurial 
inunctions,  together  with  nutritious  food,  tonics,  hygiene,  etc., 
may  arrest  its  progress.  In  marked  enlargement  resort  to 
surgical  means  is  necessary. 

ONYCHAUXIS. 

Hypertrophy  of  the  nails.  It  may  be  congenital  or  acquired, 
idiopathic  or  symptomatic.  Among  the  principal  diseases  to 
which  it  may  be  due  may  be  mentioned  syphilis,  psoriasis, 
leprosy,  ringworm,  ichthyosis,  and  neuritis.  Traumatism 
may  induce  it.     Treatment  is  unsatisfactory  and  very  variable. 

ATROPHIES  OF  THE  SKIN. 
ALBINISM. 

Albinism  consists  in  a  congenital  absence  of  pigment  in  the 
hair,  skin,  and  eyes.  The  cause  is  unknown.  It  is  believed  to  be 
influenced  by  heredity.  In  a  typical  case  the  skin  is  unusually 
white;  the  hair  is  fine  and  silky,  and  whitish  or  yellowish  white 
in  color;  the  pupils  appear  red;  and  the  irides  are  lighter  in 
color  than  normal.  Sensitiveness  .to  light,  nictitation,  nystag- 
mus, high  errors  of  refraction,  and  mental  inferiority  are  rather 
common  accompaniments.  Partial  albinism  is  common  in 
negroes  and  such  individuals  are  termed  "piebald."  Treat- 
ment is  of  no  avail. 

VITILIGO. 

Synonym. — Leukoderma. 

Description. — An  acquired  condition  characterized  by  areas 
devoid  of  pigment  surrounded  by  hyperpigmented  borders. 
It  occurs  usually  in  adult  life  and  seems  to  be  dependent  upon 


820  SCLERODERMA. 

some  disturbance  of  innervation.  Apart  from  this,  the  cause 
is  obscure.  The  affected  areas  are  attended  by  no  changes 
other  than  loss  of  pigment  which  may  also  be  absent  from  the 
hair  in  those  regions.  Its  onset  is  slow  and  its  course  indefinite. 
It  usually  persists  during  the  life-time  of  the  individual.  The 
treatment  is  unsatisfactory.  Arsenic  internally,  and  counter- 
irritation  to  the  patches  may  be  tried. 

SCLERODERMA. 

Synonyms. — Sclerema;  hidebound  disease. 

Description. — A  rare  atrophic  cutaneous  affection,  character- 
ized by  circumscribed  or  diffused  induration,  rigidity,  and 
stiffening.  It  occurs  usually  in  adult  females.  The  direct 
cause  is  unknown.  Exposure,  rheumatism,  neurotic  disturb- 
ances, etc.,  may  influence  its  production.  The  disease  begins 
with  stiffening  and  pigmentation  of  the  integument.  This  in- 
creases and  is  followed  by  induration  and  rigidity.  The  skin 
meanwhile  becoming  atrophic.  The  surface  of  the  skin  is  dry, 
smooth,  and  tense.  In  a  marked  case  the  joints  also  become 
fixed.  In  the  early  stage  the  skin  is  thickened  but  late  in  the 
disease  it  becomes  thinned.  The  course  is  chronic  and  the 
prognosis  is  unfavorable.  Massage  and  inunctions  are  of  value 
in  relieving  the  tension.     Otherwise,  treatment  is  of  no  avail. 

MORPHEA. 

Synonyms. — Addison's    keloid;     circumscribed     scleroderma. 

Definition. — An  atrophic  disease  of  the  skin,  characterized 
by  sharply  circumscribed,  firm,  whitish  yellow  patches,  sur- 
rounded by  a  violaceous  zone.  The  surface  is  smooth,  shiny, 
and  resistant.  The  lesion  is  most  common  on  the  trunk.  The 
course  is  chronic. 

Treatment. — Tonics  should  be  administered  internally,  and 
massage,  electricity,  and  the  rv:-ray  should  be  tried  locally.  The 
results  of  treatment,  however,  are  not  very  encouraging. 


CANITIES.  821 

CANITIES. 

Absence  of  pigment  in  the  hair.  It  may  be  local  or  general, 
senile  or  premature.  Permature  whitening  of  the  hair  may  be 
due  to  profound  emotional  disturbances,  fright,  shock,  fear, 
worry,  neuralgia,  vitiligo,  heredity,  etc.  It  usually  takes  place 
slowly  but  may  occur  very  suddenly.  The  treatment  consists 
in  the  application  of  hair  dyes.     Internal  medication  is  useless. 

ATROPHY  OF  THE  NAILS. 

This  may  result  from  injury,  disease  of  the  nerves,  syphilis, 
psoriasis,  ringworm,  etc.,  or  it  may  be  congenital.  The  nails 
become  lusterless,  brittle,  and  dwarfed.  Treatment  depends 
upon  the  cause  but  even  in  the  most  favorable  cases  some  de- 
formity remains. 

ALOPECIA. 

Synonyms. — Baldness;  calvities. 

Description. — Partial  or  complete  loss  of  hair.  It  may  be  con- 
genital or  acquired.  The  acquired  form  may  be  senile  or  pre- 
mature, idiopathic  or  symptomatic.  The  idiopathic  variety 
occurs  without  obvious  internal  or  external  causes  and  is  seldom 
amenable  to  any  form  of  treatment.  Symptomatic  alopecia  is 
that  form  of  the  affection  which  results  from  syphilis,  infec- 
tious fevers,  seborrhea,  lupus  erythematosus,  parasitic  diseases 
of  the  skin,  psoriasis,  eczema,  and  similar  conditions. 

The  prognosis  depends  on  the  cause.  In  congenital,  senile, 
and  idiopathic  alopecia  the  hair  seldom  regenerates.  In  symp- 
tomatic alopecia,  the  possibility  of  return  of  the  hair  is  directly 
proportionate  to  the  removability  of  the  cause. 

Treatment. — This  varies  with  the  underlying  cause.  Inter- 
nally, tonics,  especially  strychnin,  iron,  and  arsenic,  together 
v/ith  fluidextract  of  jaborandi,  lonx  (0.65  c.c),  three  times 
daily  should  be  administered.  Locally,  stimulating  applications 
should  be  made  varying  with  the  character  of  the  local  cause. 


82  2  ALOPECIA  AREATA. 

Seborrhea  being  a  very  frequent  cause,  its  treatment  is  appli- 
cable in  most  cases. 

ALOPECIA  AREATA. 

Description. — Baldness  in  circumscribed  areas.  These  areas 
occasionally  coalesce,  producing  alopecia  universalis.  Most 
cases  are  due  to  some  disturbance  of  the  nervous  system  while 
others  seem  to  owe  their  origin  to  a  parasite.  The  condition 
is  one  of  atrophy  and  affects  the  entire  hair  and  the  adjacent 
skin.  The  most  common  situations  for  the  disease  are  the 
scalp,  beard,  eyebrows,  and  eyelashes,  but  in  very  rare  instances 
the  pubio  and  axillary  hair  may  also  be  lost.  As  ordinarily  ob- 
served, the  disease  presents  one  or  more  rounded,  circumscribed, 
smooth,  white  patches  of  baldness.  There  are  no  prominent 
follicles  or  broken-off  hairs  as  in  ringworm.  The  skin  may  at 
first  be  somewhat  inflammatory  but  soon  becomes  pale  and 
atrophic.  The  onset  may  be  sudden  or  gradual  and  the  dura- 
tion is  indefinite. 

Prognosis. — The  course  is  rather  chronic.  Recovery  is  the 
rule  in  children  but  usually  requires  a  period  of  several  months. 
In  older  persons,  the  prognosis  should  be  guarded;  the  hair 
returns  but  requires  a  much  longer  period.  In  middle-aged  or 
older,  adults,  the  outlook  for  the  return  of  the  hair  is  unfavor- 
able. Relapses  are  common.  The  return  of  the  hair  is  evi- 
denced first  by  the  appearance  of  fine,  white,  downy  hairs  over 
the  affected  areas;  these  later  become  converted  into,  or  are 
replaced  by,  the  natural  hair. 

Treatment. — Tonics  should  be  administered  internally.  Ar- 
senical preparations  are  especially  valuable.  Fluidextract  of 
jaborandi,  tt]^x  (0.65  c.c),  is  very  beneficial  in  some  cases. 
Locally,  stimulating  applications  should  be  employed.  The 
following  is  an  example: 

I^.      Betanaphthol 5i  4.  gm. 

Petrolat §3  32  .  gm. 

M.  S. — Apply  locally  twice  daily. 


NEW    GROWTHS    OF    THE    SKIN.  823 

NEW  GROWTHS  OF  THE  SKIN. 
KELOID. 

Synonyms. — Cheloid;  keloid  of  Alibert. 

Description.— An  abnormal  growth  of  connective  tissue  devel- 
oped at  the  site  of  an  injury.  It  is  observed  most  frequently 
in  negroes  and  usually  follows  lacerations,  bums,  bites,  and 
destructive  lesions.  Occasionally  it  arises  spontaneously. 
In  the  early  stages,  the  growth  appears  as  a  small,  pale-red 
nodule  but  as  it  progresses  it  increases  in  size,  sending  out  claw- 
like processes.  It  is  smooth,  dense,  and  of  a  pinkish  color  but 
may  be  darkly  pigmented.  Subjective  symptoms  are  absent. 
The  affection  usually  occurs  over  the  sternum. 

Treatment.— Excision  should  never  be  performed  as  the  re- 
sulting scar  will  give  rise  to  greater  deformity  than  the  keloid. 
Multiple  scarification,  electrolysis,  mercurial  plaster,  and  the 
i^-ray  may  be  employed.  In  most  cases  the  growth  is  per- 
manent. 

XANTHOMA. 

Synonyms. — Xanthelasma;  vitiligoidea. 

Definition.— An  abnormal  cutaneous  condition  characterized 
by  the  formation  of  circumscribed  fiat  or  tubercular  yellowish 
patches.  The  fiat  variety,  xanthoma  planum,  is  most  often 
observed  on  the  eyelids  and  consists  of  smooth,  soft,  sharply 
circumscribed,  buf¥-colored,  slightly  elevated  patches.  The 
tubercular  form,  xanthoma  titberosum,  occurs  elsewhere  on  the 
body  as  variously  sized,  smooth,  elastic,  yellow  nodules. 

Causes. — Frequently  no  cause  can  be  detected.  Female  sex, 
middle   life,  jaundice,  and  diabetes  are  factors  in  some  cases. 

Treatment.— Usually  no  treatment  is  necessary,  as  the 
growths  usually  remain  stationary.  Removal  may  be  accom- 
plished by  electrolysis  if  necessary.  Excision  or  the  galvano- 
cautery  are  seldom  necessary. 


824  LUPUS   ERYTHEMATOSUS. 

LUPUS  ERYTHEMATOSUS. 

Synonyms. — Seborrhea  congestiva;  lupus  non-exedens ;  lupus 
erthyematodes ;  lupus  sebaceus. 

Definition. — A  chronic,  superficial,  new-growth  formation  of 
the  skin  characterized  by  sharply  circumscribed  reddish  patches 
covered  with  adherent  grayish  or  yellowish  scales. 

Causes. — The  etiology  is  obscure.  The  disease  is  observed 
with  greatest  frequency  in  the  female  sex  during  early  and  mid- 
dle adult  life.  Many  cases  are  preceded  by  local  congestive 
disorders  such  as  acne  rosacea,  seborrhea,  eczema  seborrhoicum, 
sunburn,  chilblains,  etc.  General  ill  health  is  also  an  etiologic 
factor.  By  many  observers,  the  affection  is  believed  to  be  an 
expression  of  tuberculosis. 

Pathology. — The  true  nature  of  the  affection  has  not  been  as 
yet  definitely  determined.  Many  observers  believe  it  to  be  a 
new  growth  while  others  view  it  as  a  chronic  inflammation. 
The  earliest  change  is  believed  to  be  capillary  obstruction. 
The  principal  structural  alterations  of  the  disease  are  to  be 
found  in  the  corium,  consisting  largely  of  a  growth  of  reticu- 
lated adenoid  tissue,  associated  with  perivascular  infiltration. 
The  excretory  parts  of  the  glandular  structures  are  to  some 
extent  infiltrated.  Edema  of  the  prickle  cells  and  cutis  is  also 
present.  The  scarring  may  result  from  degeneration  of  the 
sebaceous  glands  or  the  elastic  fibers.  The  epidermis  eventu- 
ally becomes  atrophic.  The  affection  is  believed  to  result  from 
the  toxin  of  tuberculosis,  but  the  lesion  possesses  none  of  the 
characteristics  of  tubercular  growths. 

Symptoms. — The  disease  presents  itself  in  four  clinical 
varieties:  circumscribed,  diffuse,  telangiectatic^  and  nodular. 
The  circumscribed  form  is  perhaps  the  more  common  and  is 
the  variety  usually  observed  on  the  nose,  cheeks,  ears,  and 
scalp.  Attention  is  first  called  to  the  condition  by  the  presence 
of  one  or  more  pin-head  to  pea-sized,  scaly,  reddish  spots,  the 
borders,  of  which  may  be  elevated.  They  grow  slowly,  as  a 
rule,  and  after  a  certain  size  is  attained  they  may  remain  sta- 
tionary or  coalesce  forming  large  patches.     These  patches  are 


LUPUS   ERYTHEMATOSUS.  825 

well  defined  and  sharply  marginated,  being  separated  from  the 
healthy  integument  by  an  elevated  border.  The  surface  of  the 
lesion  is  covered  with  scanty  grayish  scales  which  are  firmly 
adherent  and  project  into  the  follicular  openings.  The  central 
portion  of  the  disease  is  slightly  depressed  and  atrophic  and  the 
ducts  of  the  sebaceous  glands  are  distended  and  patulous. 
The  color  of  the  patch  is  pinkish  or  reddish  with  a  violaceous 
tinge,  most  marked  at  the  border.  On  taking  the  affected 
skin  between  the  fingers  it  is  found  to  be  infiltrated  and  thick- 
ened. Mild  itching  and  burning  are  present.  A  common 
situation  for  the  disease  is  the  face,  involving  both  cheeks  and 
the  nose  at  the  same  time  and  presenting  the  appearance  of  a 
butterfly  with  outstretched  wings.  Less  frequently  the  ears, 
scalp,  hands,  and  mucous  membranes  may  be  attacked.  The 
lesions  are  usually  symmetrically  distributed.  The  course  of 
the  disease  is  essentially  chronic.  Involution  occasionally 
occurs    spontaneously   but    malignant    changes   are    very   rare. 

Diagnosis. — Lupus  erythematosus  may  be  distinguished 
from  other  affections,  especially  lupus  vulgaris,  by  its  occur- 
rence in  adult  life,  its  slow  course,  its  symmetric  distribution, 
the  superficial  character  of  the  sharply  defined  scaly  patches 
with  distended  glandular  openings,  the  atrophic  scarring,  and 
the  absence  of  ulceration  or  nodules. 

Prognosis. — The  course  of  the  disease  is  very  chronic  and 
extends  over  several  years.  Many  cases  never  show  any  im- 
provement. A  few  undergo  spontaneous  involution;  and  a 
limited  number  respond  to  treatment.  The  prognosis  should 
always  be  guarded. 

Treatment. — Internal  treatment  has  little  or  no  effect  on  the 
disease  except  in  those  instances  in  which  definite  internal 
affections  exist,  under  which  circumstances  internal  medica- 
tion   is   indirectly   of   value.      Quinin   is   sometimes   beneficial. 

Locally,  moderately  stimulating  applications  are  of  most 
benefit.  A  common  practice  is  to  wash  the  face  nightly  with 
soap  (green  soap  if  the  patch  appears  sluggish)  and  apply 
some  preparation   of   sulphur  such  as: 


826  LUPUS    VULGARIS. 

I^.      Sulph.  precip 5i  4  •  gm- 

Petrolat 5i  32  .  gm. 

M.  S. — Apply  locally. 

Or— 

I^.      Zinc  sulphat 

Potass,  sulphurat aa    oi  4.  gm. 

Aquae f  5iv  120.  c.c. 

(Dissolve  separately  and  then  mix.) 
S. — "  Lotio  Alba" — apply  locally. 

If  much  roughness  or  irritability  results : 

I^.      Sulph.  precip 

Acid,  salicyl aa  gr.  x  0.6  gm. 

Ung.  aqu«  rosae 5i  32  .     gm. 

M.  S. — Apply  locally  (Stelwagon). 

Unna  applies  a  paint  consisting  of  10  parts  of  collodion  and 
I  to  2  parts  of  green  soap  to  which  3  to  5  per  cent,  of 
salicylic  acid  may  be  added  to  increase  its  activity.  The  appli- 
cation of  mercurial  plaster  and  the  painting  of  the  lesion  with 
liquor  potassae,  carbolic  acid,  salicylic  acid,  or  resorcin  in  collo- 
dion, iodin,  and  silver  nitrate  deserve  passing  mention.  Strong 
caustics  are  occasionally  employed  but  the  scarring  they  induce 
is  a  disadvantage.  Among  other  measures  useful  at  times  may 
be  mentioned  freezing  with  ethyl  chlorid,  scarification,  curet- 
ting, electrolysis,  galvanocauterization,  phototherapy,  and 
radiotherapy. 

LUPUS  VULGARIS. 

Synonyms. — Lupus  exulcerans;  lupus  exedens;   lupus  vorax. 

Definition. — A  neoplastic  cellular  infiltration  caused  by  the 
tubercle  bacillus,  producing  papules,  nodules,  and  patches 
which    either    -ulcerate    or    atrophy,     leaving    scars    (Crocker). 

Cause. — The  direct  cause  is  the  tubercle  hacillus.  The  disease 
usually  begins  in  the  first  or  second  decade  of  life  and  is  never 
congenital.      In   many   cases   there  is  an  hereditary  predisposi- 


LUPUS    VULGARIS.  827 

tion.     Some  cases  result  from  local  inoculation.     Evidences  of 
tuberculosis  elsewhere  are  often  present. 

Pathology.— The  process  consists  essentially  of  a  small  round- 
cell  infiltration  beginning  in  the  corium  and  gradually  invading 
the  other  layers.  Circumscribed  areas  are  encountered  which 
possess  all  the  structural  characteristics  of  miliary  tubercles 
(epithelioid  cells,  giant  cells,  etc.).  Tubercle  bacilli  may  be 
demonstrated  but  are  very  scant.  Necrotic  degeneration  takes 
place  in  these  areas  followed  by  proliferation  of  the  connective- 
tissue  cells  and  the  production  of  scar  tissue. 

Symptoms.— The  disease  usually  begins  on  the  face  as  one  or 
more  deep-seated,  pin-point  to  pin-head  dull  red  spots.  These 
gradually  develop  into  small,  semitranslucent  browti  nodules 
("apple-jelly  nodules  of  Jonathan  Hutchinson").  As  the  dis- 
ease progresses,  these  nodules  extend  and  eventually  coalesce 
forming  dull  red,  soft,  elevated  patches  with  firm,  more  or  less 
nodular  borders.  More  or  less  scaliness  may  be  present.  The 
nodules  may  remain  stationary  for  a  variable  period  but  always 
terminate  either  with  ulceration  with  scar  formation  or  in  ab- 
sorption. A  fully  developed  patch  of  lupus  tissue  shows  the 
presence  of  papules,  nodules,  fiat  infiltrations,  ulceration,  scar 
formation,  and  atrophic  areas  in  varying  degrees.  At  times 
papillomatous  outgrowths  may  be  found  on  the  border.  Fre- 
quently the  lesion  shows  retrograde  changes  at  one  side  and  on 
the  other  evidences  of  advancement.  Slight  pain  may  be 
present.     The  course  is  very  chronic. 

Diagnosis. — The  characteristic  features  of  this  disease  that 
serve  to  distinguish  it  from  syphilis,  epithelioma,  and  other  ul- 
cerative affections  are :  the  beginning  early  in  life,  the  slow  course, 
and  the  superficial  ulcerations,  together  with  papules,  semitrans- 
lucent nodules,  fiat  infiltrations,  and  scarring.  The  ulcers  are 
multiple,  have  soft  undermined  edges,  and  give  rise  to  little  or 
no  pain. 

Prognosis. — In  cases  in  which  the  lesions  are  small  and  the 
patient  is  young,  cure  may  be  effected  by  appropriate  treatment. 
Usually  the  disease  is  refractory  to  treatment,  and  when  one 
patch  is  destroyed  another  makes  its  appearance.      The  course 


828  LUPUS    VULGARIS. 

is  essentially  chronic  and  the  duration  indefinite.  The  possi- 
bility of  systemic  infection  should  be  borne  in  mind. 

Treatment. — In  all  cases,  the  patient  should  receive  the  treat- 
ment recommended  for  tuberculosis  in  general,  in  addition  to  the 
various  local  measures  for  the  diseased  integument. 

Locally,  perhaps  the  most  beneficial  with  the  least  deleterious 
results  is  the  ^-ray  treatment.  Phototherapy,  after  the  method 
of  Finsen  is  of  value  but  requires  a  long  period  of  treatment  to  be 
of  value.  Radium  has  also  been  reputed  to  be  of  benefit  but  ob- 
servations have  been  few  in  this  direction.  Extirpation  of  the 
diseased  structure  has  been  practised  extensively.  This  may  be 
accomplished  by  curetting,  cauterization,  electrolysis,  or  excision. 
The  caustics  most  commonly  employed  for  this  purpose  are 
pyrogallic  acid  (20  per  cent,  plaster),  arsenous  acid  (30  per  cent. 
paste),  and  chlorid  of  zinc.  The  galvanocautery  and  Paquelin 
cautery  are  also  used.  Scarification  is  also  a  useful  method  of 
treatment  in  some  cases. 

Frequently  when  first  encountered,  the  lesion  is  in  an  irritable 
state  either  as  the  result  of  previous  treatment  or  of  unknown 
causes.  In  such  cases,  soothing  applications  are  of  benefit.  Cal- 
amin  lotion,  diachylon  ointment,  and  the  ointment  of  the  oleate 
of  mercury  (10  per  cent.),  i  dram  to  the  ounce  of  ointment  base. 
Brooke  advises  the  following: 

I^.      Hydrarg.    oleat     (5     per 

cent.) Si  32.     gm. 

Pulv.  zinci  oxidi 

Pulv.  amyli aa  5ii  8 .     gm. 

Vaselin. 3iv  16.     gm. 

Acid.  saHcyl gr.  xx  1.3  gm. 

Ichthyol nxxx  i .  3  gm. 

M.  S. — Apply  locally  twice  daily. 

Plasters  are  often  of  value,  particularly  mercurial  plaster,  sali- 
cylic acid  plaster  (20  per  cent.),  and  resorcin  plaster.  Various 
other  modes  of  treatment  may  be  employed  according  to  the 
indications. 


SCROFULODERMA.  829 

SCROFULODERMA. 

Description. — A  tuberculous  condition  of  the  skin  occurring  in 
strumous  individuals  characterized  by  ulceration  and  associated 
usually  with  suppurating  lymphatic  glands.  The  disease  begins 
in  the  lymphatic  glands  which  undergo  necrosis  discharging 
through  the  overlying  skin.  The  ulceration  in  the  skin  is  vio- 
laceous in  color  and  has  thin  undermined  edges,  its  base  being 
made  up  of  pale  granulations.  These  ulcers  may  occur  anywhere 
on  the  body  but  are  most  common  on  the  neck.  They  spread 
slowly  and  sometimes  show  a  tendency  to  heal  and  form  con- 
nective tissue.  Other  manifestations  of  the  strumous  diathe- 
sis such  as  otorrhea,  ocular  inflammations,  lympathic  enlarge- 
ments, etc.,  are  often  present. 

Treatment. — The  general  health  should  receive  careful  atten- 
tion. Cod-liver  oil,  syrup  of  the  iodid  of  iron,  hydriodic  acid, 
quinin,  and  similar  drugs  should  be  administered.  Fresh  air, 
sunlight,  exercise,  bathing,  nutritious  food,  and  other  similar 
measures  should  be  prescribed. 

Locally,  salicylic  acid  (gr.  x  )  in  lead  plaster  (50  per  cent.)  is 
a  very  efflcient  application.  The  oleate  of  mercury,  and  boric 
acid  may  also  be  used.  The  most  efficient  method  of  treatment 
is  extirpation  and  this  may  be  accomplished  by  curetting,  ex- 
cision, or  the  use  of  caustics  such  as  pyrogallol. 

SYPHILODERMA. 

Synonyms. — Syphilis  cutanea;  syphilis  of  the  skin. 

Definition. — A  chronic,  specific,  contagious,  hereditary  disease 
characterized  for  the  most  part  by  lesions  of  the  skin  but  may 
affect  any  tissue  of  the  body.  It  is  caused  by  the  Treponema 
pallidum,  called  also  SpirochcEta  pallida. 

The  period  of  incubation  between  the  time  of  exposure  and 
the  appearance  of  the  first  manifestation  is  about  three  weeks. 
This  initial  manifestation  may  appear  as  a  scaly  papule,  super- 
ficial erosin  with  an  indurated  base,  or  the  ordinarly  chancre. 
Within  a  month  or  six  weeks  after  the  appearance  of  the  initial 
lesion  the  characteristic  cutaneous  eruption  becomes  manifest. 


830  SYPHILODERMA. 

Symptoms. — The  eruption  of  syphilis  consists  of  nearly  every 
form  of  primary  lesions  occurring  on  the  skin,  including  macules, 
papules,  pustules,  tubercles,  vesicles,  blebs,  and  ulcerations  (gum- 
mas). They  may  be  conveniently  divided  into  those  of  the  sec- 
ondary and  those  of  the  tertiary  period. 

The  secondary  eruptions  include  the  macular,  papular,  pustular, 
bullous,  and  in  very  rare  instances  vesi-eular  manifestations. 
They  appear  usually  within  four  to  six  weeks  after  the  initial 
lesion.  They  are  generalized,  symmetric,  and  copper-colored 
and,  as  a  rule,  devoid  of  itching.  In  negroes,  itching  is  often 
present.  The  presence  of  several  types  of  lesions  in  various 
stages  of  development  (polymorphism)  and  the  tendency  to 
gyrate  configuration  are  characteristic  of  this  disease.  Asso- 
ciated with  these  dermal  manifestations  are  headache,  malaise, 
fever,  muscular  and  osseous  pains,  enlargement  of  the  glands, 
sore  throat,  loss  of  hair,  anemia,  and  failing  health.  Pigmen- 
tation often  follows  the  disappearance  of  these  lesions  and  lasts 
a  considerable  period. 

The  tertiary  eruptions  include  the  tubercular  and  gummatous 
lesions.  These  are  circumscribed,  non-inflammatory,  and 
asymmetric.  They  are  deep-seated  and  tend  to  destructive 
changes. 

The  macular  syphiloderm  or  roseola  is  characterized  by  the 
appearance  of  variously  sized  and  shaped  ill  defined  macules, 
at  first  rose-red  but  later  brownish,  most  marked  in  the  trunk. 
The  face  is  free  in  cases.  The  lesions  consist  of  hyperemia 
with  slight  cellular  infiltration  in  contradistinction  to  the  other 
lesions  in  which  there  is  a  dense,  circumscribed,  round-cell 
infiltration. 

Diagnosis. — The  history,  the  absence  of  catarrhal  symptoms, 
the  presence  of  the  enlarged  glands  and  induration  of  the  chancre, 
loss  of  hair,  crescentic  arrangement  of  the  eruption,  the  absence 
of  itching,  the  presence  of  moist  papules,  and  the  color  of  the 
lesions  will  serve  to  distinguish  this  condition  from  tinea  versi- 
color, measles,  and  eruptions  resulting  from  the  ingestion  of  drugs 
and  certain  kinds  of  food. 

The  papular   syphiloderm  may  appear  as  the  large  or  small 


SYPHILODERMA.  83 1 

papular  eruption  and  may  occur  either  as  an  early  or  late  mani- 
festation. The  large  papular  syphilide  is  characterized  by 
sharply  defined,  flat,  brownish  red  lesions  varying  in  size  from 
I  /8  to  1 1 2  inch  in  diameter.  They  are  widely  distributed,  occur- 
ring with  greatest  frequency  on  the  forehead,  back  of  the  neck, 
chin,  arms,  legs,  and  genitalia.  When  occurring  on  mucous  sur- 
faces or  on  opposing  skin  surfaces  they  are  transformed  into  moist 
papules  or  "mucous  patches."  Moist  papules  may  become  the 
seat  of  vegetative  growths.  When  the  large,  dry  papular  syphilo- 
derm  desquamates  the  eruption  is  termed  papulosquamous. 
Such  eruptions  are  most  commonly  encountered  on  the  palms  of 
the  hands  and  the  soles  of  the  feet.  The  small  papular  syphilo- 
derm  consists  of  a  profuse  eruption  of  pin-head  to  millet-sized  seed, 
round  or  acuminate  papules  most  marked  on  the  trunk,  arms, 
and  legs.  They  possess  the  grouping  and  color  characteristic  of 
syphilitic  eruptions  in  general. 

Diagnosis.— While  the  eruption  for  the  most  part  is  papular, 
other  types  are  usually  present  coincidently  and  this  polymorph- 
•  ism,  together  with  the  history,  distribution,  grouping,  absence  of 
subjective  symptoms,  and  the  presence  of  concomitant  signs  of 
syphilis  serve  to  distinguish  this  form  of  the  disease  from  psoriasis, 
lichen  ruber,  lichen  scrofulosorum,  keratosis  pilaris,  and  other 
affections. 

The  vesicular  syphiloderm  is  the  rare  type  of  the  disease.  It 
consists  of  small  umbilicated  vesicles  occurring  when  the  skin  is 
thin.  Many  of  these  become  pustules  before  being  detected. 
Other  lesions  are  present  at  the  same  time,  thus  distinguishing 
it  from  eczema,  herpes  zoster,  herpes  simplex,  dermatitis  herpet- 
iformis, etc. 

The  pustular  syphiloderm  presents  several  features  worthy  of 
passing  mention.  In  some  cases  the  lesion  is  small  and  acumin- 
ated {miliary  pustular  syphiloderm)  varying  in  size  from  a  pin- 
head  to  a  millet-seed,  and  situated  on  a  dull -red  base.  The  erup- 
tion is  widely  distributed  and  may  be  grouped  or  disseminated. 
The  pustules  are  situated  at  the  openings  of  the  follicles.  The 
pustules  in  other  cases  are  large  and  acuminated  resembling  the 
lesions   of  acne   and   small-pox    (varioliform    syphilide).     Such 


S^2  SYPHILODERMA. 

lesions  are  most  frequently  found  in  the  scalp,  face,  and  trunk, 
and  are  accompanied  by  superficial  ulceration.  The  pustules  in 
syphilis  are  sometimes  small  and  fiat,  resembling  impetigo  (im- 
petiginous  syphilis).  The  lesions  of  this  form  seldom  exceed 
the  size  of  a  pea  and  show  a  marked  tendency  to  arrange  them- 
selves in  irregular  groups.  They  are  most  often  situated  on  the 
nose,  around  the  mouth,  and  in  the  hairy  regions. 

They  rupture  early,  giving  rise  to  yellowish,  greenish,  or  brown- 
ish crusting,  on  removal  of  which  ulceration  is  exposed  to  view. 
Another  variety  of  pustular  syphilis  is  that  in  which  the  lesions 
are  large  and  fiat,  resembling  ecthyma.  These  pustules  are 
about  the  size  of  the  finger-nail  and  are  situated  upon  a  dark-red 
base.  Crusting  is  profuse  and  beneath  it  there  is  ulceration.  It 
occurs  usually  upon  the  back,  shoulders,  and  extremities.  Rupia 
is  a  malignant  form  of  this  large,  fiat  pustular  syphiloderm  char- 
acterized by  abundant  greenish,  blackish  crusts  arranged  in  con- 
centric strata  beneath  which  deep  ulceration  is  taking  place. 

Diagnosis. — It  is  very  important  to  distinguish  this  form  from 
the  affections  it  resembles  for  obvious  reasons.  In  acne  there  are 
no  concomitant  signs  of  syphilis,  the  affection  is  chronic,  the 
lesions  consist  of  papules,  pustules,  and  tubercles,  and  ulcera- 
tion is  absent.  In  small-pox  there  are  severe  constitutional 
symptoms  of  a  different  nature  from  those  in  syphilis,  the  lesions 
are  first  papular  with  shot-like  induration,  then  vesicular  with 
umbilication,  and  finally  pustular;  and  the  concomitant  signs  of 
syphilis  are  absent. 

The  tubercular  syphiloderm  occurs  as  a  manifestation  of  the 
tertiary  stage  of  the  disease  and  is  characterized  by  reddish 
brown,  smooth,  deep-seated  nodules,  varying  in  size  from  a  pea 
to  a  hazel  nut,  and  arranged  in  incomplete  circles,  upon  the 
coalescence  of  which  serpiginous  patches  are  often  formed  (ser- 
piginous tubercular  syphiloderm) .  Occasionally  these  lesions  are 
disseminated.  The  termination  of  this  form  of  syphilis  is 
either  disappearance  by  absorption  followed  by  pigmentation, 
or  by  ulceration  and  scarring. 

Diagnosis. — The  tubercular  syphilide  may  be  mistaken  for 
lupus  vulgaris,  but  it  begins  at  a  much  later  age,  has  an  entirely 


SYPHILODERMA.  833 

different  history,  the  concomitant  signs  of  syphilis  may  often  be 
detected,  and  the  course  is  more  rapid.  In  syphilis  the  nodules 
are  hard,  the  ulcers  are  deep-seated  and  have  sharp-cut  edges 
and  profuse  discharge  and  crusting,  and  the  resultant  scars 
are  smooth,  soft,  and  white.  Syphilis  responds  to  treatment  with 
mercury  and  the  iodids. 

The  gummatous  syphiloderm  is  the  late  tertiary  manifesta- 
tion and  consists  of  a  sharply  defined  infiltration  of  the  skin 
and  subcutaneous  tissue  which  appears  as  one  or  more  rounded, 
painless,  non-infiammatory  tumors.  It  begins  ver^^  small  and 
slowly  increases  until  it  reaches  about  the  size  of  a  walnut, 
when  it  suppurates  and  discharges  through  the  skin,  leaving 
behind  a  clear-cut  deep  ulcer.  The  resultant  scar  is  white  and 
smooth  and  somewhat  depressed.  The  history,  course,  and  char- 
acter of  the  ulcer  separate  it  from  other  ulcerating  conditions. 

The  bullous  syphiloderm  occurs  most  often  in  children  as  a 
manifestation  of  congential  syphilis  {pemphigoid  syphilide)  but 
also  late  in  the  acquired  variety  of  the  disease  in  individuals  in 
poor  health.  The  blebs  are  discrete  and  their  contents  are  at  first 
serous  and  later  purulent.  As  they  dry  they  form  dark  crusts 
beneath  which  ulceration  takes  place. 

Hereditary  syphilis  presents  all  the  cutaneous  eruptions  com- 
m.on  to  the  acquired  form  but  lacks  the  initial  lesion.  The  skin 
manifestations  appear  usually  within  the  first  six  or  eight  weeks, 
the  most  frequent  of  which  are  the  macular,  papular,  and  bullous. 
The  macular  eruption  consists  of  copper-colored  spots  and 
patches  situated  on  the  palms,  soles,  genitalia,  and  buttocks, 
associated  with  an  apparent  eczema  intertrigo  and  a  few  moist 
papules.  The  papular  variety  may  coexist  w^th  the  macular 
and  present  the  usual  characteristics.  The  bullous  form  of  the 
eruption  is  the  most  serious  type  of  hereditary  syphilis.  The 
blebs  are.  usually  present  at  birth  and  are  observed  in  most  cases 
on  the  soles,  palms,  and  on  the  toes  and  fingers,  sometimes  in- 
terspersed with  macules  and  papules.  The  bullae  are  discrete, 
flaccid,  and  surrounded  by  a  brownish  ring  of  infiltration.  The 
base  is  ulcerated  or  excoriated.  The  concomitant  signs  in 
hereditary  syphilis  include  constant  coryza  ("snuffies"),  emacia- 
53 


834  SYPHILODERMA. 

tion,  apparent  senility,  mucous  patches,  Hutchinson's  teeth,  and 
dactylitis. 

Prognosis. — In  most  cases  in  which  the  treatment  can  be 
properly  carried  out  the  prognosis  as  to  cure  is  favorable.  A 
very  few  cases  progress  toward  a  fatal  termination  in  spite  of 
treatment.  Partially  treated  cases  are  liable  to  be  masked  and 
the  disease  manifest  itself  internally.  In  infants,  the  outlook  is 
uncertain.  In  all  cases,  the  prognosis  depends  on  the  general 
health  of  the  patient,  the  severity  of  the  attack,  and  whether  the 
appropriate  treatment  can  be  instituted. 

Treatment. — The  indications  are  to  restore  the  patient's  gen- 
eral health  by  the  use  of  iron,  quinin,  strychnin,  etc.,  and  combat 
the  disease  by  mercury  and  the  iodids.  In  the  early  secondary 
eruptions  various  preparations  of  mercury,  particularly  the  prot- 
iodid,  the  bichlorid,  the  biniodid,  mercury  and  chalk,  and 
mercurial  ointment  in  inunctions  are  indicated,  being  careful 
to  prevent  ptyalism.  In  hereditary  syphilis,  mercurial  inunc- 
tions are  of  most  value.  In  the  tubercular  and  gummatous 
lesions  of  the  skin,  potassium  or  sodium  iodid  in  from  5  to  10 
gr.  doses  is  the  drug  to  be  employed.  Larger  doses  than  these 
are  usually  unnecessary  In  the  intermediary  stages  both  mer- 
cury and  potassium  iodid  should  be  administered.  Usually 
the  mercurial  medication  is  given  by  the  mouth,  but  inunctions, 
subcutaneous  and  intravenous  injections,  and  fumigations  are 
also  employed.  No  matter  what  method  is  employed  the  mer- 
curial should  be  given  continuously  for  a  year  to  eighteen 
months  and  followed  by  potassium  iodid  for  six  months  or  a 
year  according  to  the  symptoms. 

Locally,  applications  are  usually  made  only  when  the  lesions  are 
moist  or  ulcerative.  In  diffuse  macular  and  papular  eruptions 
a  bichlorid  of  mercury  bath  (i  to  5000)  or  dusting  with  calomel 
may  be  prescribed.  For  moist  papules  calomel  dusting  powder 
is  indicated.  In  tubercular  or  gummatous  lesions,  ammoniated 
mercury  and  mercurial  plaster  are  of  value.  In  offensive  ulcer- 
ations potassium  permanganate,  bichlorid  of  mercury,  black 
wash,  etc.,  should  be  employed. 


HYPERIDROSIS.  835 

DISORDERS  OF  SECRETION. 
HYPERIDROSIS. 

Synonyms. — -Hydrosis;  ephidrosis;  idrosis. 

Definition. — A  disorder  of  the  sweat  glands,  characterized  by 
an  increased  secretion  of  sweat.  The  sweating  may  be  either 
general  or  local. 

Causes. — Unknown.  It  may  be  inherited.  Disorders  of  the 
sympathetic  nervous  system  give  rise  to  it  in  many  instances. 
The  condition  is  purely  functional  in  character. 

Symptoms. — The  affection  may  be  unilateral  or  bilateral,  local 
or  general,  acute  or  chronic,  and  constant  or  paroxysmal.  The 
quantity  of  secretion  may  be  comparatively  small  or  very  large. 

Local  hyperidrosis  occurs  most  commonly  upon  the  palms, 
soles,  axillae,  and  genitalia. 

Hyperidrosis  of  the  palms  may  be  so  profuse  that  the  fluid 
accumulates  and  keeps  the  parts  constantly  macerated,  the 
wearing  of  gloves  being  impossible,  for  as  soon  as  the  parts  are 
wiped  dry  they  are  again  bathed  in  the  secretion.  Jamieson 
states  that  hyperidrosis  of  the  hands  is  very  common  in  those 
who  are  daily  excessive  spirit  drinkers. 

Hyperidrosis  of  the  soles  is  a  disagreeable  and  often  distressing 
condition,  as  the  socks  and  shoes  become  saturated,  and  thus 
keep  the  soles  constantly  bathed,  allowing  the  macerated  epider- 
mis to  peel  off,  leaving  a  more  tender  skin  exposed,  causing  pain 
and  distress  when  walking.  The  maceration  of  the  epidermis, 
and  the  secretion  about  the  toes,  together  with  the  moisture  of 
the  socks  and  the  soles  of  the  shoes,  produce  a  most  disagreeable, 
disgusting,  and  persistent  odor,  which  is  termed  hromidrosis 
pedum, 

Hyperidrosis  of  the  genitalia  attacks  males  more  particularly, 
giving  rise  to  a  disagreeable,  penetrating  odor. 

Broifiidrosis  is  the  designation  when  the  secretion  has  an  offen- 
sive odor. 

Chromidrosis  is  the  designation  when  the  fluid  poured  forth  is 
variously  colored. 


836  HYPERIDROSIS. 

Uridrosis  is  the  designation  when  the  excretion  from  the  sweat 
glands  contains  the  elements  of  the  urine,  and  particularly 
urea. 

Phosphoridrosis  is  the  designation  when  the  perspiration  ap- 
pears luminous  in  the  dark. 

Hematidrosis  is  the  designation  when  the  sweat  contains 
blood. 

Prognosis. — The  majority  of  cases  are  extremely  intractable, 
but  in  local  hyperidrosis,  particularly  of  the  feet,  the  prognosis 
is  favorable.      Relapses  may  occur. 

Treatment. — If  the  sweating  is  generalized,  a  careful  search 
should  be  made  to  determine  the  underlying  systemic  cause 
and  the  internal  treatment  should  be  governed  accordingly. 
Atropin  sulphate,  gr.  1/120  to  1/60  (0.00034  to  o.ooi  gm.), 
twice  daily,  ergot  in  pill  or  solution,  agaracin,  gr.  1/6  (o.oii  gm.), 
gallic  acid,  quinin,  mineral  tonics,  and  sulphur,  5i  (4  gm.), 
twice  daily,  have  been  highly  reccommended  for  this  condition. 

Local  treatment,  however,  is  more  efficacious.  The  parts 
should  be  cleansed  and  immediately  dried,  and  then  dusted 
with  some  one  of  the  numerous  dusting  powders.  The  foUow- 
is  a  valuable  powder. 

I^.      Acidi  salicylic! ;  .  .  .    gr.  xx  i  .3  gm. 

Zinci  cleat oj  32.     gm. 

M.  S.— Use  locally. 

Perhaps  the  very  best  local  application  is  tincture  of  bella- 
donna either  diluted  or  full  strength.  Aristol  as  a  dusting 
powder  is  very  satisfactory. 

In  hyperidrosis  of  the  palms  and  soles,  the  following  are  valu- 
able, first  washing  the  parts  with  a  weak  solution  of  carbolic  acid : 

I^.      Acidi  salicylici 5ss  2 .  gm. 

Cretse  praep oj  32  .  gm. 

Aluminis  exsic §j  32.  gm. 

M.  et  powder  finely. 

S. — Apply  to  parts  with  puff-ball. 


HYPERIDROSIS.  837 

Or— 

I^.      Acid,  salicylici 3   parts. 

Pulv.  amyli 10  parts. 

Pulv.  soapstone 87  parts. 

M.  S. — vSift  into  shoes  and  stockings. 

Or— 

I^.      Sulphur,  loti gr.  xxx  2 .        gm. 

Pulv.  arrowroot. 5iv  16.        gm. 

Acid,  salicylici gr.  vij  0.45  gm. 

M.  S. — Dust  over  feet  and  between  toes. 

Or— 

I^.     Potassii  permanganat .  .  .    gr.  ij  o.  13  gm. 

Aquae  destil f  5j  30.        c.c. 

M.  S. — Apply  locally. 

A  saturated  solution  of  boric  acid,  alone  or  in  powder,  with 
equal  parts  of  acetanilid,  applied  frequently  to  the  hands  and 
feet,  often  proves  curative. 

For  obstinate  cases,  involving  the  palms  or  soles,  the  follow- 
ing plan  of  treatment,  as  suggested  by  Hebra,  will  be  found  of 
the  greatest  service.  It  is  imperative  that  the  various  steps  be 
closely  followed: 

"  The  parts  are  to  be  cleansed  with  water  and  soap,  and  the 
following  ointment  applied  on  pieces  of  cloth  cut  to  the  size  of 
the  region.  Lint  smeared  with  the  ointment  is  also  to  be  placed 
between  the  toes  or  fingers,  so  that  every  portion  of  the  skin  may 
be  covered  with  a  layer  of  the  ointment. 

I^.      Emplast.  diachyli oiv  120.  gm. 

Olei  olivse foiv  120.  c.c. 

The  plaster  to  be  melted  and  the  oil  added  and  stirred  until 
a  homogeneous  mass  results. 

S. — To  be  used  on  cloths. 

"  The  clothes  are  to  be  changed  every  twelve  hours,  when  the 
parts  are  not  to  be  washed,  but  rubbed  with  dry  lint  and  starch 
dusting  powder,  after  which  new  dressings  are  again  to  be  ap- 
plied in  the  same  manner.  This  proceeding  is  to  be  continued 
from  one  to  two, weeks.     When  the  disease  is  upon  the  soles,  the 


838  ANIDROSIS. 

patient  may  walk  about  in  loose  shoes."  After  a  week  or  ten 
days  the  ointment  may  be  discontinued,  but  the  dusting  powder 
is  to  be  used  for  a  considerable  period.  If  relapses  occur,  the 
original  treatment  should  again  be  instituted. 

Painting  the  soles  and  under  and  between  the  toes  with  a  i 
per  cent,  solution  of  formalin  morning,  noon,  and  night,  has  given 
good  results  in  a  number  of  instances,  A  few  drops  of  the  solu- 
tion may  be  put  in  the  boot  or  shoe. 

Among  other  methods  of  treatment  may  be  mentioned  the  ap- 
plication of  a  I  per  cent,  alcoholic  solution  of  quinin,  the  use  of 
astringent  lotions  containing  alum,  tannic  acid,  and  similar  sub- 
stances (oi  to  viii  to  the  pint  of  water),  the  dusting  of  tartaric 
acid  on  the  parts  when  there  are  no  abrasions,  and  the  employ- 
ment of  electricity. 

ANIDROSIS. 

Definition. — A  functional  disorder  of  the  sweat  glands,  charac- 
terized by  a  diminished  or  insufficient  secretion  of  sweat. 

Causes. — Anidrosis  may  be  due  to  a  congenital  deficiency  of 
the  sweat  glands  or  it  may  result  from  injury  to  a  nerve,  during 
the  course  of  chronic  diseases  of  the  skin,  as  ichthyosis,  eczema, 
psoriasis,  lepra,  and  elephantiasis  arabum.  In  rare  cases  an  in- 
dividual ceases  to  sweat  entirely  at  times ;  in  such  cases  the  gen- 
eral health  is  impaired,  and  during  the  hot  season  much  suffer- 
ing may  result. 

Treatment. — The  activity  of  the  skin  and  sweat  glands  should 
be  promoted  by  the  ingestion  of  large  quantities  of  water,  hot 
baths,  steam  baths,  friction,  electricity,  and  the  use  of  sudorifics, 
especially  pilocarpin.  In  congenital  cases,  the  treatment  is  of  no 
benefit.  The  harshness  and  dryness  of  the  skin  in  such  cases 
may  be  relieved  to  some  extent  by  oily  applications. 

SUDAMINA. 

Synonyms. — Sudamen;  miliaria  crystallina  (Hebra). 
Definition. — ^A     noninflammatory     affection     of     the    sweat 
glands;  characterized  by  the  rapid  development  of  millet-seed- 


MILIARIA.  839 

sized,  translucent,  whitish  vesicles  in  great  numbers  upon  any 
portion  of  the  body. 

Cause. — A  high  bodily  temperature,  causing  unusual  activ- 
ity of  the  sudoriparous  glands.  The  affection  is  common  in 
febrile  diseases. 

Pathology. — The  glands  being  excited  beyond  their  capacity 
for  normal  excretion,  the  excessive  fluid,  instead  of  escaping 
upon  the  surface,  collects  between  the  layers  of  the  epidermis, 
in  the  form  of  minute,  translucent  pin-point-sized   vesicles. 

Symptoms. — An  ephemeral  rash.  Each  minute  vesicle  is  dis- 
tinct, but  they  exist  in  great  numbers,  very  closely  resembling 
drops  of  free  sweat.  They  develop  rapidly,  never  coalesce,  be- 
come puriform,  or  rupture.  Fresh  crops  form  from  time  to 
time.  Their  duration  is  transitory;  the  fluid  is  absorbed,  the 
covering  of  each  dries,  forming  a  thin,  delicate  membrane, 
which  disappears  as  a  slight  desquamation. 

Treatm.ent.- — The  treatment  is  that  of  the  disease  with  which 
they  occur. 

MILIARIA. 

Synonyms. — Lichen  tropicus;  miliaria  rubra;  miliaria  alba; 
prickly  heat. 

Definition. — An  acute  inflammation  of  the  sw^eat  glands,  char- 
acterized by  the  development  of  discrete,  whitish  or  reddish,  pin- 
point and  millet-seed-sized  papules,  vesicles,  or  vesiculopapules, 
production  of  prickling,  tingling,  and  burning  sensations  of  a 
m.ost  aggravated  character,  associated  with  more  or  less  malaise. 

Causes. — Excessive  heat,  the  result  of  excessive  or  tightly 
fitting  clothing,  or  a  high  external  temperature  is  the  exciting 
cause.  The  affection  is  most  frequent  in  fleshy  adults  who  per- 
spire freely,  and  in  children.  Nervous  prostration,  severe  dys- 
pepsia and  general  debility  seem  to  predispose  to  "prickly  heat." 

Varieties. — Miliaria  papulosa;  miliaria  vesiculosa. 

Pathology. — The  pathology  of  the  two  varieties  is  the  same — 
both  inflammatory  affections  of  the  sweat  glands;  in  the  one 
papules,  in  the  other  vesicles,  develop  about  the  orifices  of  the 
excretory  ducts. 


840  MILIARIA. 

In  either  variety  occurs  hyperemia  of  the  vascular  plexus  of 
the  sweat  glands,  followed  by  slight  exudations  about  the  ducts, 
giving  rise  to  the  minute  papules  or  vesicles,  which  remain  until 
the  cause  has  been  modified  or  removed,  when  they  are  rapidly 
absorbed. 

Symptoms. — Miliaria  papulosa,  known  as  lichen  tropicus  and 
"  prickly  heat,"  is  of  sudden  onset,  with  the  occurrence  of  numer- 
ous minute,  acuminated  bright-red  papules,  about  the  size  of  a 
pin-head  or  millet-seed,  and  but  slightly  raised  above  the  level 
of  the  skin.  The  papules  are  preceded  by  and  accompanied 
with  sweating  (hyperidrosis)  and  distressing,  tingling,  pricking, 
'  and  burning  sensations.  If  the  attack  be  severe,  vesicopapules 
and  vesicles  are  freely  interspersed  among  the  numerous  papules. 
Rarely  the  secretion  of  sweat  is  notably  diminished. 

Miliaria  vesiculosa;  in  this  variety,  instead  of  papules,  im- 
mense numbers  of  vesicles  develop,  of  the  size  of  pin-points  and 
pin-heads,  of  a  whitish  {uiiliaria  alba)  or  yellowish-white  color. 
The  surface  from  which  they  arise  is  of  a  bright-red  color,  owing 
to  each  vesicle  being  surrounded  by  an  areola  {miliaria  rubra). 
The  vesicles  are  preceded  and  accompanied  by  sweating  (hyper- 
idrosis) and  most  distressing  tingling,  pricking,  and  burning 
sensations. 

Either  variety  may  attack  all  parts  of  the  body,  but  the  ab- 
domen, chest,  back,  neck,  and  arms  are  regions  usually  invaded. 

Duration. — This  varies  with  the  cause.  It  may  appear,  fully 
develop,  and  disappear  in  a  few  hours.  In  those  predisposed 
it  may  continue  more  or  less  marked  throughout  the  entire 
summer. 

Diagnosis. — If  the  cause,  nature,  and  seat  of  the  affection  are 
taken  into  consideration,  no  error  should  occur. 

Eczema  papulosum  has  a  resemblance  to  "prickly  heat,"  but 
the  course  of  eczema  is  slow,  and  the  papules  are  larger,  more 
elevated,  and  firmer  than  those  of  miliaria  papulosa. 

Eczema  vesiciilosum  and  miliaria  vesiculosa  are  to  be  differ- 
entiated by  the  marked  differences  in  the  progress  of  each — the 
former  slow,  the  latter  rapid ;  the  vesicles  of  the  former  rupturing 
spontaneously,  those  of  the  latter  only  when  severely  irritated. 


SEBORRHEA.  84 I 

Sudamen  is  not  an  inflammatory  affection    while  miliaria  is. 

Prognosis. — The  affection  is  often  most  rebellious  in  fleshy  per- 
sons and  children,  and  if  neglected  it  passes  into  eczema  or  an 
erythematous  intertrigo. 

Treatment. — The  patient  should  be  kept  as  cool  as  possible, 
and  avoid  undue  perspiration.  The  food  should  be  light  and 
unstimulating,  dispensing  with  meats  and  condiments  for  a  few 
days;  wine,  spirits,  and  beer  are  to  be  avoided. 

The  ingestion  of  water,  lemonade,  Appollinaris  water,  Vichy 
water,  together  with  refrigerant  diuretics,  as  potassium  citrate 
or  acetate,  a  cool  apartment,  and  absolute  rest  will  ordinarily 
insure  speedy  relief.      Saline  cathartics  are  invaluable. 

Locally,  sponging  with  alkaline  solutions,  dilute  subacetate  of 
lead  solution,  fluidextract  of  grindelia  (well  diluted),  or  a  solu- 
tion of  witchhazel  is  beneficial.  Cupric  sulphate  solution  (gr.  x 
to  the  ounce),  carbolic  acid  (gr.  xx),  and  glycerite  of  starch 
(oiii),  and  a  dusting  powder  composed  of  lycopodium,  starch, 
and  zinc  oxid  may  also  be  employed.  The  application  of  boric- 
'  acid  solution  followed  by  boric-acid  powder  is  a  valuable  method 
of  treatment. 

SEBORRHEA. 

Synonyms. — Pityriasis;  dandruff';  tinea  furfuracea. 

Definition. — A  functional  disorder  of  the  sebaceous  glands  of 
the  skin,  characterized  by  an  excessive  or  diminished  and  ab- 
normal secretion  of  sebaceous  matter,  forming  upon  the  skin 
either  as  an  oily  coating  or  in  crusts  and  scales. 

Varieties. — Seborrhea  oleosa;  seborrhea  sicca. 

Causes. — In  newly  born  infants  an  increased  secretion  of  seba- 
ceous   matter — the    vernix    caseosa  —  is    a    physiologic  process. 

The  origin  of  the  disease  is  not  fully  understood,  anemia  being 
a  factor  in  many  cases.  Brunettes  are  more  often  affected  than 
blondes,  and  women  more  frequently  than  men. 

Pathology. — Seborrhea  is  a  functional  derangement  of  the 
sebaceous  glands;  if  it  be  allowed  to  become  very  chronic,  there 
occurs  atrophy  of  the  glands  and  follicles. 


842  SEBORRHEA. 

Symptoms. — The  affection  may  occur  upon  any  portion  of  the 
body  its  most  frequent  seat  being,  however,  the  scalp  {seborrhea 
capitis  or  pityriasis  capitis),  and  next  in  frequency  the  face 
{seborrhea  faciei) . 

Seborrhea  oleosa  appears  as  an  oily,  greasy  coating  upon  the 
skin,  without  hyperemia,  and  not  attended  with  itching.  The 
secretion  is  of  an  oily  character,  the  quantity  at  times  being  so 
great  as  to  collect  in  minute  drops  of  a  clear,  yellowish  fluid 
upon  the  surface.  The  most  common  seat  for  this  variety  is 
the  face — seborrhea  faciei — and  nose — seborrhea  nasi. 

Seborrhea  sicca  consists  in  the  formation  of  dry,  more  or  less 
greasy,  masses  of  scales  or  crusts  of  a  grayish,  yellowish,  or 
brownish-yellow  color,  having  a  strong  tendency  to  adhere  to 
the  skin,  and  attended  with  decided  itching.  Occurring  upon 
the  scalp — seborrhea  capitis — it  is  a  frequent  source  of  prema- 
ture baldness. 

Diagnosis. — Seborrhea  capitis  may  be  mistaken  for  dry  eczema, 
but  the  former  is  always  a  dry  disease,  while  in  eczema  moisture 
has  occurred  at  some  period  of  the  affection.  The  scales  in 
seborrhea  are  very  abundant  and  pale;  in  eczema  the  scales  are 
scanty  and  reddish,  the  parts  irritated,  infiltrated,  and  thickened. 

Seborrhea  sicca  and  psoriasis  have  many  points  of  resemblance 
whether  occurring  on  the  scalp  or  on  the  body.  In  seborrhea 
the  scales  are  minute  or  caked,  grayish  or  yellowish  in  color,  of 
an  unctuous  feel,  and  usually  uniformly  diffused.  In  psoriasis 
the  scales  are  very  dry,  abundant,  thick,  white,  irregularly  dis- 
persed, with  intervening  healthy  skin,  and  the  surface  beneath 
the  scales  is  always  reddish  and  inflamed.  The  clinical  histories 
of  each  are  entirely  different. 

Prognosis. — If  properly  treated,  favorable,  although  the  affec- 
tion is  obstinate  to  eradicate.  Its  tendency  to  produce  prema- 
ture loss  of  hair  when  occurring  on  the  scalp  should  be  borne  in 
mind. 

Treatment. — The  condition  of  the  general  health  should  receive 
attention.  The  secretions  should  be  regulated.  Anemia, 
chlorosis,  gastrointestional  disorders,  and  other  general  condi- 
tions   should    receive    appropriate    treatment.      Iron,    arsenic. 


SEBORRHEA.  843 

ichthyol,  and  calcium  sulphid,  internally,  are  of  especial  value 
in  this  condition.  The  following  formula  of  Erasmus  Wilson  is 
often  of  benefit: 

I}.      Vini  ferri f  oiss  45  .  c.c. 

Syr.  simplicis 

Liq.  potassii  arsenit  .  .aa  f  5ij  aa  8.  c.c. 

Aquae  destil f  5ij  60  .  c.c. 

M.  S. — Teaspoonful  three  times  a  day,  well  diluted. 

Local  treatment  is  of  greatest  importance.  In  seborrhea  of 
the  scalp  the  scales  and  crusts  should  first  be  removed  by  olive 
oil,  cod-liver  oil,  or  lard  applied  at  night  and  the  head  covered 
with  a  flannel  or  other  cap.  A  mixture  of  boroglycerin  (oii) 
and  rose  water  (oviii)  applied  on  gauze  is  also  of  value  in  this 
connection.  As  soon  as  the  crusts  are  well  soaked,  they  should 
be  removed  by  washing  with  soap  and  warm  water,  or  equal 
parts  of  soap,  glycerin,  and  water,  or  the  following: 

I^.      Tinct.  sapo.  mollis f  5iv  120.  c.c. 

Spt.  vini  rect f  oij  60.  c.c. 

Solve  et  filtra. 

M.  S. — Dilute  and  use  as  a  soap-wash  or  shampoo. 

After  removing  the  crusts,  the  scalp  should  be  washed  with 
warm  water  and  carefully  dried.  In  most  cases,  an  ointment 
such  as  the  following,  rubbed  well  into  the  roots  of  the  hair,  is 
very  beneficial: 

I^.      Sulph.  precip 5i  4  •     gm. 

Acid  salicyl gr-  x  0.6  gm. 

Petrolat Bi  32 .     gm. 

M.  S. — Part  the  hair  and  apply  directly  to  the  scalp  every 
night. 

Or— 

ly;.      Hydrarg.  ammoniat gr.  xx  i  .3  gm. 

Lanolin oii  8 .     gm. 

Petrolat 5vi  24 .     gm. 

M.  S. — Apply  locally  as  directed. 


844  SEBORRHEA. 

The  boroglycerid  mixture  mentioned  above  or  the  following 
combination  is  useful  for  dandruff: 

I^.      Acid,  boric oi  4 .  gm. 

Alcohol    (50  per  cent.)- ■  •     oiv  120.  gm. 

M.  S. — Apply  locally. 

Or— 

J\.     Acid  .carbol 5ss  to  oi  2  .  to  4  .  gm. 

01.  amygdalae f  5iv     ~  15.               c.c. 

01.  limonis f  oi  4.              c.c. 

Aq.  destillat .  .  .q.  s.  ad  fgii  60.              c.c. 

M.   S. — Apply  locally  after  washing  (Van  Harlingen). 

Or— 

I^.      Resorcin oss  to   oj         2  .  to  4  .  gm. 

Ung.  aquse  rosas oi  32 .  gm. 

M.   S. — Apply  locahy. 

Or— 

I^.      Resorcin oss  2 .     gm.  - 

Olei.  ricini n|xv  i  .  o  c.c. 

Alcohol. f  5iii  90.     c.c. 

M.  S. — Apply  locally  by  means  of  a  medicine  dropper. 
(For  brunettes  only.) 

Or— 

I^.      Tinct.  cantharidis foiij  12.  c.c. 

Tinct.  capsici f  5iij  12  .  c.c. 

01.  ricini f  5ij  8  .  c.c. 

Alcoholis. f  Sij  60.  c.c. 

Spt.  rosmarini f  o  j  30 .  c.c. 

M.  S. — Apply  locally  (Duhring). 

Or— 

I^.      Bismuthi  subnitratis .  .  .  .     oj  4.  gm. 

Ung.  hydrargyri  ammon- 

iat oij  8  .  gm. 

Ung.  aquae  rosas ad    oj  ad  32.  gm. 

M. 

Seborrhea  elsewhere,  is  treated  in  a  similar  manner,  modify- 
ng  the  applications  according  to  the  individual  needs  of  the  case. 


PRURITUS.  845 

DISORDER  OF  SENSATION. 
PRURITUS. 

A  functional  disorder  of  the  skin  characterized  essentially  by- 
itching  without  structural  alterations  or  obvious  cause.  Itch- 
ing due  to  other  disturbances  is  termed  symptomatic  and  its 
relief  depends  upon  the  removability  of  the  underlying  condition. 
Primary  pruritus  is  difficult  to  permanently  cure  but  relief  may 
be  afforded  by  the  use  of  applications  containing  carbolic  acid, 
menthol,  thymol,  chloral-camphor,  liquor  carbonis  detergens, 
and  similar  antipruritics.  Idiopathic  pruritus  is  by  no  means 
common  and  a  careful  search  will  usually  detect  some  underly- 
ing condition  for  the  apparent  primary  itching,  removal  of 
which  relieves  the  pruritus.  Frequently,  cases  without  obvious 
cause  come  under  observation  which  require  symptomatic  treat- 
ment while  a  search  is  being  made  for  the  underlying  condition. 
For  such  cases  the  following  formulas  are  applicable: 

I^.      Acid,  carbol oii  8.  c.c. 

Glycerin oii  8  .  c.c. 

Aquae Oi  480  .  c.c. 

M.  S. — Poison,  apply  locally  as  directed. 

Or— 

I^.      Liq.  carbonis  deterg 5ii  8.  c.c. 

Aquae oviii  240.  c.c. 

M.  S. — Apply  locally. 

Or— 

I^.      Thymol oii  8  .  gm. 

Liq.  potass 5i  4  .  c.c. 

Glycerin 5iii  12  .  c.c. 

Aquse oviii  240  .  c.c. 

■   M.  S. — Apply  locally  (Crocker). 

Or— 

T^.      Resorcin 5ss  2 .  gm. 

Glycerin oi  4  .  c.c. 

Liq.  calcis f  5iv  120.  c.c. 

M.  S. — Apply  locally. 


846  PRURITUS. 

Generalized  itching  nearly  always  suggests  infection  by  some  of 
the  animal  parasites,  especially  scabies.  When  the  scratch- 
marks  are  localized  for  the  most  part  to  the  flexor  surfaces  it  is 
a   good  plan  to  advise  the  following: 

I^.      Sulph.  precip. 

Betanaphthol aa    oss  aa  2  .  gm. 

Petrolat oi  32.  gm. 

M.  S. — Apply  to  all  parts  of  the  body,  excepting  the  head 
and  face,  for  four  nights;  then  follow  with  a  bath.  Should 
the  itching  then  continue,  do  not  repeat  the  treatment  at 
once,  but  instead  use  a  carbolic-acid  lotion  for  a  week  or 
ten  days  and  then  return  to  the  first  treatment  if  necessary. 

Menthol  is  frequently  of  value  in  relieving  itching,  especially 
when  incorporated  in  an  ointment  or  paste. 

I^.      Menthol gr.  viii  48 .  ^m. 

Pulv.  amyli 

Pulv.  zinci  oxidi aa    5ii  8 .        gm. 

Petrolat 3iv  16.       gm. 

M.  S. — Apply  locally. 

Brocq    advises    the    following    formulas    for    this    condition: 

I^,     Resorcin g^-  ^^  0.25  gm. 

Hydrarg.  chlorid.  mit .  .  .  gr.  xii  o.  75  gm. 

Zinc  oxidi gr.  xxx  2  ,  gm. 

Petrolat 3v  20.  gm. 

M.     Ft.  ung. 
S. — Apply  locally. 

I^.     Menthol.. gf- iii  0.2     gm. 

Acidi  carbolici gr.  iv  0.25  gm. 

Acidi  salicyli oss  2 .        gm. 

Zinci  oxidi 5iss  6 .        gm. 

Liq.  petrolat oi  32.       gm. 

M.     Ft.  ung. 

S. — Apply  locally. 

Pruritus  ant  is  perhaps  the  most  distressing  form  of  this 
disease  and  for  its  permanent  relief  most  careful  attention 
must  be  given  to  the  most  minute  details  of  the  case.  The 
following  formulas  are  recommended  for  relief  of  the  itching: 


PRURITUS.  847 

I^.      Hydrarg.  ammoniat gr.  xx  1.2  gm. 

Adipis  benzoinat 5i  32.     gm. 

M.  S. — Apply  locally  (Crocker). 
I^.     Menthol, 
Chloral, 

Camphor aa  gr  v  ,3  gm. 

Petrolat §ss  16.     gm. 

M.  S. — Apply  locally. 

I^.      Cocain.    hydrochlorid .  .  .  gr.  xv  i.  gm. 

Bismuth,  subnitrat gr.  xxx  2.  gm. 

Lanolin 5v  20.  gm. 

M.  S.— Apply  locally. 

When  complicated  with  hemorrhoids,  the  following  is  often 
of  value : 

I^.     Fluidext.  hamameHdis .  .  5viii  30.     c.c. 
Ext.  hydrastis, 

Ergotin aa  oxv  60.     c.c. 

Tinct.. benzoin 3xv  60.     c.c. 

Olei  olivse 5viii  30.     c.c. 

Acid,  carbol gr.  xxiii  i .  5  c.c. 

M.  S. — For  external  use. 

Malcolm  Morris  speaks  favorably  of  the  following  combina- 
tions in  the  treatment  of  pruritus  ani : 

I^.     Acidi  carboHci itlxx  i  .  2  c.c. 

Cocain.  hydrochlorid.  .  .  .    gr.  x  .6  gm. 

Vaselin §i  32 .     gm. 

M.     Ft.  ung. 

S. — Apply  locally. 

^.      Ung.  picis  Hquidas 5i  4.     gm. 

Bismuthi  subnitratis  .  .  .  .    gr.  xx  1.2  gm. 

Adipis q.  s.  ad    oi  32.     gm. 

M.     Ft.  ung. 

S. — Apply  locally. 

Laplace  advises  the  following  formula  for  certain  cases  of 
anal  itching: 

Py;.      Hydrarg.  chlorid.  corrosiv  gr.  ii  .12  gm. 

Acid,  hydrochlor ttj^x  .12  c.c. 

Aquae f  gviii  240.        c.c. 

M.    S.— Apply  locally. 


INDEX 


Abdominal  aorta,  aneurysm  of,  473 

dropsy,  331 

typhus,  16 
Abnormal  pulsations,  409 

states  of  the  blood,  388 
Abscess,  cerebral,  607,  612 

of  the  brain,  612 

of  the  heart,  453 

of  the  liver,  302 

of  the  lung,  129 

perinephritic,  372 

tonsillar,  213 
Absent  respiration,  491 
Acarus,  797 

Acetic  acid,  tests  for,  222 
Acetone  in  the  urine,  345 
Achorion  schoenleinii,  794 
Achylia  gastrica,  229 
Acid,  acetic,  222 

butyric,  222 

dyspepsia,  250 

lactic,  222 
Acidity  of  the  gastric  contents,  220,  221 
Acne,  764 

artificialis,  766 

atrophica,  766 

cachecticorum,  765 

hypertrophica,  766 

indurata,  765 

papulosa,  765 

punctata,  765 

punctata  albida,  816 

punctata  nigra,  814 

pustulosa,  765 

rosacea,  769 

tubercula,  765 

vulgaris,  764 
Acquired  feeble-mindedness,  718 

hydrocephalus,  622 
Acromegaly,  693 
Action  of  heart,  412 

54 


Active  congestion  of  the  kidneys,  350 

dilatation  (cardiac),  499 
Acute  alcoholism,  188 

anterior  poliomyelitis,  636 

articular  rheumatism,  121 

ascending  paralysis,  646 

Bright 's  disease,  352 

bronchial  catarrh,  524 

bronchitis,  524 

catarrhal  enteritis,  263 
laryngitis,  511 

coryza,  505 

croupous  nephritis,  352 

cystitis,  379 

dementia,  719,  720 

desquamative  nephritis,  352 

diarrhea,  263 

diseases,  definition  of,  3 

dyspepsia,  224 

eczema,  737,  740 

encephalitis,  607 

endocarditis,  426 

farcy,  94 

gastritis,  224 

glanders,  93 

gout,  170 

hepatitis,  302 

hydrocephalus,  585,  622 

indigestion,  253 

infectious  cholecystitis,  321 

inflammation  of  the  gall-bladder,  321 

leptomeningitis,  581 

mania,  700 

meningitis,  581 

miliary  tuberculosis,  388 

myelitis,  631 

myocarditis,  453 

nasal  catarrh,  505 

nephritis,  362 

pancreatitis,  322 

parenchymatous  nephritis,  352 


849 


850 


INDEX. 


Acute  pericarditis,  419 

phthisis,  142 

rheumatism,  121 

rhinitis,  505 

tonsillitis,  213 

tubal  nephritis,  352 

uremia,  373 

yellow  atrophy,  304 
Addison's  disease,  403 

keloid,  820 
Adherent  pericardium,  424 
Adhesive  pericarditis,  424 
After-sensations,  574 
Agraphia,  613 
Ague,  41 

fever  and,  41 
Air  in  the  pleural  cavity,  566 
Albinism,  819 
Albumin  in  the  urine,  340 
Albuminoid  liver,  309 
Albuminuria,  chronic,  355 
Alcohol,  test  for,  222 
Alcoholic  dementia,  720 

paralysis,  662 

pneumonia,  133 
Alcoholism,  188 
Alexia,  590,  613 
Alibert,  keloid  of,  823 
Alopecia,  821 

areata,  822 

universalis,  822 
Alphos,  675 

Alternating  insanity,  708 
Alvine  flux,  259 
Ameba  coli,  103 
American  disease,  the,  687 

gout,  173 
Ammonio-magnesium  phosphate,  337 
Ammonium  urate,  338 
Amnesia,  590 
Amnesic  aphasia,  613 
Amphoric  note,  486 

respiration,  494 

voice,  499 
Amygdalitis,  213 
Amyloid  kidney,  364 

liver,  309 

reaction,  310,  365 
Amyotrophic  lateral  sclerosis,  641,  646 

paralysis,  657 
Anachlorhydria,  221 


Analgesia,  574 
Anasarca,  418 
Anchylostoma  duodenale,     291,   292,   293, 

294,  296 
Anchylostomiasis,  296 
Anemia,  390 

cerebral,  593 

essential,  396 

idiopathic,  396 

lymphatic,  401 

of  the  skin,  724 

primary,,  390 

progressive  pernicious,  396 

secondary,  390 

splenic,  402 

tunnel,  296 
Anemic  murmurs,  414 
Anesthesia,  572 

of  the  skin,  573 
Aneurysm  of  the  abdominal  aorta,  473 

of  the  aorta,  469 

of  the  aortic  arch,  470 

of  the  thoracic  aorta,  453 
Angina,  chronic,  211 

Ludovici,  206  .  . 

membranous,  82 

simple,  210 
"Angina  sine  delore,"  465 
Anginoid  scarlet  fever,  61 
Angioneurotic  edema,  732 
Anhydremia,  389 
Anidrosis,  838 
Ankle-clonus,  572 
Anopheles,  41,  42,  46 

fever,  41 
Anterolateral  sclerosis,  646 
Anthrax,  116 

benigna,  782 

edema,  malignant,  117 

intestinal,  117 
Anuria,  334 

Aorta,  aneurysm  of,  469 
Aortic  insufficiency,  433 

obstruction,  440 

regurgitation,  433,  43  s 

stenosis,  435,  440 
Aphasia,  590,  613 

amnesic,  613 

ataxic,  613 
Aphthae,  204 
Aphthous  fever,  94 


IDDEX. 


851 


Aphthous  stomatitis,  202 
Apoplexy,  595 
Appendicitis,  277,  286 
*Apraxia,  590 
Apyretic  pneumonia,  134 
Arachnitis,  581 

Argyll-Robertson  pupil,  577,  649 
Argyria,  805 
Arm-jerk,  572 
Arrhythmia,  417,  463 

cordis,  463 
Arteries,  diseases  of  the,  467 
Arteriocapillary  fibrosis,  467 
Arteriosclerosis,  467 
Arthritis  deformans,    167 

rheumatoid,  167 

scarlatinal,  65 
Arthropathies,  575 
Articular  rheumatism,  acute,  121 

rheumatism,  chronic,  163 
Artisan's  cramp,  690 
Ascaris  lumbricoides,  291,  292 
Ascending  paralysis,  acute,  645 
Ascites,  331 
Asiatic  cholera,  95 
Aspiration  pneumonia,  134 
Association  of  the  physical  signs,  499 
Asthma,  540 

bronchial,  540 

hay,  53  7 

spasmodic,  540 

thymic,  518 
Ataxia,  Friedreich's,  657 

hereditary,  656 

locomotor,  648 
Ataxic  aphasia,  613 

gait,  S70 

paraplegia,  652,  657 

paraplegia  hereditary,  656 
Atheroma,  467,  817 
Athetoid  movements,  570 
Atonic  dyspepsia,  250 
Atrophic  cirrhosis  of  the  liver,  306 

paralysis  of  children,  634 

rhinitis,  508 
Atrophies  of  the  skin,  819 
Atrophy,  acute  yellow,  304 

chronic  spinal  muscular,  641 

lipomatous  muscluar,  644 

of  the  liver,  304 

of  the  muscles,  575 


Atrophy  of  the  nails,  821 

optic,  57  7 

progressive  muscular,  641 
Auditory  center,  590 

vertigo,  615 
Aura  epileptica,  678 
Aural  vertigo,  515 
Auscultation,  487 

of  the  precordium,  411 
Auscultatory  percussion,  487 
Automatism,  epileptic,  679 
Autumnal  catarrh,  537 

fever,  16 
Axis-cylinder  process,  588 

Babinski's  reflex,  572 
Baccelli's  sign,  564 
Bacillus  anthracis,  116 

coli  communis,  277 

dysenteriae,  142 

icteroides,  44 

Klebs-Loeffler,  82,  83,  87 

Koch's,  95,  141 

leprae,  161 

mallei,  93 

of  diphtheria,  82,  83,  87 

of  Eberth,  16,  23 

of  Pfeiifer,  13 

of  Shiga,  103 

pestis.  III 

tetani,  112 

tuberculosis,  141 
Baldness,  821 
Barbers'  itch,  791 
Barlow's  disease,  179 
Basedow's  disease,  404 
Basilar  meningitis,  585 
Basophiles,  387 
Bell's  palsy,  673 
Bends,  the,  659 
Beri-beri,  665 
Bile  in  urine,  344 
Bile-ducts,  catarrh  of,  315 
Biliary  calculi,  317 

passages,  diseases  of,  315 
Bilious  cholera,  268 

fever,  48 

headache,  619 

malignant  fever,  53 

penumonia,  133 

remittent  fever,  48 


852 


INDEX. 


Biliousness,  300 
Black  death,  1 1 1 
Black  measles,  67 

stools,  260 

vomit,  53 
Black-heads,  814 
Blackwater  fever,  52 
Bladder,  catarrh  of,  379 

diseases  of,  350 
Blebs,  723 

Bleeder's  disease,  177 
Blood,  abnormal  states  of  the,  388 

casts,  347,  348 

currents,  414 

diseases  of,  382 

examination  of,  382 

in  chlorosis,  393 

in  leukocythemia,  400 

in  pernicious  anemia,  397 

in  urine,  344 

microscopic  examination  of  the,  38: 

occult,  245 
Blood-supply  of  the  brain,  588 

of  the  dura,  578 
Bloody  flux,  103 

stools,  260 
Boas  and  Ewald's  test-meal,  219 
Boas'  test,  221 
Boettger's  test,  342 
Boils,  780 

Bothriocephalus  latus,  288 
Bowels,  inflammation  of,  263 
Brachycaria,  462 
Bradycardia,  417,  462 
Brain,  abscess  of,  607,  612 

congestion  of,  591 
Brand  bath,  27 
Break-bone  fever,  58 
Breast-pang,  464 
Breath,  foul,  209 
Breathing,  alterations  in,  576 
Bright 's  disease,  352,  355,  359,  362,  364 
Bromidrosis,  835 
Bromidrosis  pedum,  835 
Bronchial  asthma,  540 

catarrh,  524 
acute,  524 
chronic,  529 

dilatation,  530 

fremitus,  481 

hemorrhage,  549 


Bronchial  rales,  495 

respiration,  488,  493 

tubes,  diseases  of,  524 

whisper,  499 
Bronchiectasis,  529 
Bronchitis,  acute,  524 

capillary,  555 

chronic,  529 

fetid,  529 

fibrinous,  535 

membranous,  535 

plastic,  535 

secondary,  529 
Bronchophony,  498 
Bronchopneumonia,  555,  526 
Broncho-pulmonary  hemorrhage,  549 
Bronchorrhagia,  549 
Bronchorrhea,  529,  530 
Bronzed-skin  disease,  403 
Bruce's  micrococcus,  40 
Bubonic  plague,  1 1 1 
Bulbar    paralysis,     chronic     progressive 

639 
Bullae,  723 

Bullous  syphiloderm,  833 
Burrow,  798 
Butyric  acid,  tests  for,  222 

Cachexia,  malarial,  52 

strumipriva,  406 
Caisson  disease,  659 
Calcium  oxalate,  338  340 
Calculi,  biliary,  317 

hepatic,  317 

pancreatic,  325 

renal,  368 
Callositas,  807 
Callosity,  807 
Callus,  807 
Calvities,  821 
Cammidge  reaction,  325 
Cancer,  gastric,  328 

hepatic,  313 

of  the  esophagus,  217 

of  the  liver,  313 

of  the  pancreas,  324 

of  the  stomach,  238 
Cancrum  oris,  205 
Canities,  821 
Canker,  202 
Capillary  bronchitis,  555 


INDEX. 


8S3 


Capsular  hemorrhage,  597 
Carbuncle,  782 
Carbunculus,  782 
Carcinoma,  gastric,  238 

of  the  liver,  313 

of  the  stomach,  238 
Cardiac  space,  410 
Cardialgia,  246 
Cardiosclerosis,  454 
Carditis,  453 

chronic,  454 
Carphologia,  22 
Caseous  phthisis,  144 

pneumonia,  144 
Casts,  347 
Catalepsy,  576 
Catarrh  of  the  bile-ducts,  315 

of  the  bladder,  379 

chronic  gastric,  229 
nasal,  508 

dry,  529 

epidemic,  12 

gastric,  224 

intestinal,  263 

mucous,  529 

of  the  rectum,  281 
Catarrhal  croup,  82,  516 
/  enteritis,  263 

fever,  12 

laryngitis,  511 

nephritis,  350 

phthisis,  144 

pneumonia,  555 

stomatitis,  201 
Causalgia,  574 
Cavernous  rales,  496 

respiration,  493 
Cellulitis  of  the  neck,  206 
Centers,  cerebral,  590 
Centrum  ovale  hemorrhage,  597 
Cephalodynia,  164,  165 
Cerebellar  hemorrhage,  598 
Cerebral  abscess,  607,  612 

anemia,  593,  602 

apoplexy,  595 

congestion,  591 

embolism,  602 

fever,  581 

hemorrhage,  595 

hyperemia,  591 

localization,  589 


Cerebral  membranes,  578 
diseases  of,  578 
softening,  602 

symptoms  in  cardiac  disease,  419 

thrombosis,  602 

tumors,  609 
Cerebrospinal  fever,  34 

meningitis  epidemic,  34 

sclerosis,  653 
Cerebrum,  diseases  of,  587 

microscopic  anatomy  of,  588 
Cervicobrachial  neuralgia,  669 
Cervicooccipital  neuralgia,  668 
Cestodes,  287 

Changes  in  respiration,  491 
Charbon,  116 

Charcot-Leyden  crystals,  503 
Charcot's  joints,  650 
Cheiropompholyx,  760 
Cheloid,  823 
Chest  divisions,  475 
Chest-sounds  in  health,  488 
Cheyne- Stokes  respiration,  458,  576 
Chicken-pox,  77 
Child-crowing,  518 
Children,  atrophic  paralysis  of,  636 

essential  paralysis  of,  636 
Chill,  congestive,  49 
Chills  and  fever,  41 
Chiragra,  170 
Chloasma,  804 

uterinum,  805 
Chlorids,  339 
Chlorosis,  392  ,-, 

Egyptian,  296 
Choked  disk,  577 

Cholecystitis,  acute  infectious,  321 
Cholelithiasis,  317 
Cholera,  95 

Asiatic,  95 

asphyxia,   98 

bilious,  268 

English,  268 

epidemic,  95 

infantum,  214 

malignant,  95 

morbus,  268 

nostras,  268 

sicca,  98 

sporadic,  268 

typhoid,  95 


854 


INDEX. 


Choleriform  diarrhea,  274 
Cholerine,  97 
Cholesterin,  340,  342,  504 
Chorea,  675 

Huntington's,  676 
Choreiform  movements,  570 
Chromidrosis,  835 
Chromophytosis,  793 
Chronic  albuminuria,  355 

alcoholism,  188,  189,  191 

angina,  211 

articular  rheumatism,  163 

Bright's  disease,  355,  359,  362,  364 

bronchial  catarrh,  529 

bronchitis,  529 

carditis,  454 

catarrhal  pneumonia,  144 

coryza,  508 

croupous  nephritis,  355 

cystitis,  379 

delusional  insanity,  712 

dementia,  720 

diarrhea,  261,  262 

disease,  definition  of,  3 

dysentery,  103,  106 

dyspepsia,  229 

eczema,  737,  744 

endocarditis,  430 

enteritis,  264 

farcy,  94 

gastric  catarrh,  229 

gastric  ulcer,  237 

gastritis,  229 

glanders,  93 

gout,  171 

hydrocephalus,  623 

indigestion,  253 

interstitial  myocarditis,  454 
nephritis,  359,  362 
pneumonia,  559 

laryngitis,  520 

mania,  703 

melancholia,  696 

myocarditis,  454 

nasal  catarrh,  508 

nephritis,  362 

pancreatitis,  323 

parenchymatous  nephritis,  355,    362 

pericarditis,  424 

pharyngitis,  211 

phthisis,  146,  148 


Chronic  poliomyelitis,  641 

progressive  bialbar  paralysis,  639 

spinal  muscular  atrophy,  641 

stomatitis,  202 

rhinitis,  508 

tubal  nephritis,  355 

ulcerative  phthisis,  148 

valvular  disease,  430 
Chronic  eczema,  734,  737 
Circular  insanity,  707 
Circulatory  system,  diseases  of,  408 
Circumscribed  aneurysm,  470 

pericarditis,  419 

scleroderma,  820 
Cirrhosis  of  the  liver,  305 

of  the  lungs,  152,  559 
Cirrhotic  kidney,  359,  362 
Classification  of  insanity,  694 
Clavus,  684,  808 
Clergyman's  sore  throat,  211 
Clinical  history,  definition  of,  3 
Coating  of  the  tongue,  207 
"Cold  on  the  chest,"  524 
"Cold  in  the  head,"  505 
Cold  sore,  761 
Colic,  hepatic,  317 

intestinal,  256 

renal,  368 

stomachic,  246 
Color  of  the  blood,  383 
Coma,  576 

diabetic,  186 
Combined  lateral  and  posterior  sclerosis, 

652 
Comedo,  814 
Comma  bacillus,  95 
Compensation,  cardiac,  43 1 
Compensatory  hypertrophy,  431 
Concentric  hypertrophy  (cardiac),  447 
Confluent  small-pox,  7 1 
Congenital  hydrocephalus,  623 
Congestion,  hypostatic,  552 

of  the  brain,  591 

of  the  kidneys,  350 

of  the  liver,  300 

of  the  lungs,  552 

spinal,  625 
Congestive  chill,  49 

fever,  49 
Conjugate  deviation  of  the  eyes,  577 
Consciousness,  disturbances  of,  576 


INDEX. 


855 


Constipation,  257 

of  infants,  259 
Constitutional  diseases,  16,3 
Consumption,  141,  148 

throat,  522 
Contagious  disease,  2 

fever,  32 
Continued  fever,  7,  ir 
Contracted  kidney,  359,  362 
Convulsions,  569 
Cor  bovinum,  433,  447 
Corrigan's  disease,  152 

hammer,  193 

pulse,  417,  436 
Corn,  808 
Corset-liver,  299 
Cortical  hemorrhage,  597 
Coryza,  acute,  505 

chronic,  508 
Coster's  paste,  790 
Costiveness,  257 
Cough, 501 

winter,  529 
Coup-de-soleil,  198 
Cow-pox,  75 
Cracked-pot  sound,  487 
Cramp,  artisan's  690 
Crepitant  rale,  496 
Cretinism,  406 
Crisis,  definition  of,  4 

of  locomotor  ataxia,  650 
Croup,  catarrhal,  82,  516 

false,  82,  516 

membranous,  82 

spasmodic,  82,  516 

true,  82 
Croupous  enteritis,  266 

nephritis,  acute,  352 
chronic,  355 

pneumonia,  127 

stomatitis,  202 
Crus  cerebri  hemorrhage,  597 
Crusta  lactea,  735 
Culex,  42 
Culex  fa,tigans,  59 
Cuniculus,  798 
Curschmann's  spirals,  503 
Cutaneous  reflexes,  571 
Cyanosis,  418 
Cyclical  insanity,  708 
Cylindric  aneurysm,  470 


Cylindroids,  350 
Cyst,  sebaceous,  817 
Cysticercus  bovis,  288 

cellulosae,  288 
Cystin,  339,  340 
Cystitis,  379 

acute,  379 

chronic,  379 
Cysts  of  the  pancreas,  324 

sebaceous,  817 
Cytoryctes  vacciniae,  75 

variolae,  70 


Dancer's  cramp.  690 
Dandruff, 841 
Dandy  fever   58 
Davy's  test  for  urea,  336 
Deafness,  577 
Death,  black,  1 1 1 
Decubitus,  575 
Deep  cardiac  space,  411 
Definition  of  insanity,  694,  699 
Degeneration  of  the  muscles,  575 
Degeneration,  reactions  of,  638 
Degenerative  neuritis,  662 
Degrees  of  pyrexia,  6 
Delayed  conduction,  574 
Delirium,  694 

tremens,  188,  189,  190 
Delusion,  693    710 
Delusional  insanity,  709,  712 

mania,  709 

melancholia,  709 
Dementia,  718 

apoplectica,  720 

choreica,  720 

epileptica,  721 

senilis,  721 

paralytica,  720 

paretic,  714 

syphilitica,  721 

toxica,  721 
Demodex  folliculorum,  815 
Dengue,  57,  58 
Depression  of  spirits,  696 
Dermatitis,  778 

calorica,  778 

exfoliativa,  780 

factitia,  780 

herpetiformis,  757 


856 


INDEX. 


Dermatitis,  medicamentosa,  779 

traumatica,  778 

venenata,  778 
Dermoid  reaction,  Sahli's,  223 
Desquamative  nephritis,  acute,  352 
Disease,  or  diseases: 

acute,  3 

Addison's,  403 

American,  the,  687 

Barlow's,  179 

Basedow's,  404 

Bright's,  352,  355,  359,  362,  364 

bronzed-skin,  403 

caisson,  569 

chronic,  3 

chronic  valvular,  430 

constitutional,  163 

contagious,  2 

definition  of,  i 

Duhring's,  757 

endemic,  3 

epidemic,  3 

fish-skin,  809 

foot  and  mouth,  94 

Friedreich's,  656 

general  nervous,  675 

Graves',  404 

Hodgkin's,  401 

infectious,  2,  5 

Meniere's,  615 

mental,  693 

nervous,  general,  675 

of  the  arteries,  467 

of  the  bile  passages,  315 

of  the  bladder,  350 

of  the  blood,  382 

of  the  bronchial  tubes,  524 

of  the  cerebral  membranes,  578 

of  the  cerebrum,  587 

of  the  circulatory  system,  408 

of  the  digestive  system,  200 

of  the  ductless  glands,  382 

of  the  endocardium,  426 

of  the  esophagus,  216 

of  the  gall  bladder,  315 

of  the  intestines,  253 

of  the  kidneys,  350 

of  the  larynx,  511 

of  the  liver,  298 

of  the  lungs,  545 

of  the  mouth,  200 


Disease  of  the  myocardium,  446 

of  the  nasal  passages,  505 

of  the  nerves,  660 

of  the  nervous  system,  568,  578 

of  the  pancreas,  322 

of  the  pericardium,  419 

of  the  peritoneum,  326 

of  the  pharynx,  210 

of  the  pleura,  560 

of  the  respiratory  system,  475 

of  the  skin,  722 

of  the  spinal  cord,  625 

of  the  stomach,  218 

of  the  tongue,  207 

of  the  tonsils,  210 

of  the  urinary  organs,  334 

pandemic,  3 

parasitic,  of  the  skin,  785 

Parkinson's,  691 

Parry's,  404 

Raynaud's,  688 

Schonlein's,  181 

Sporadic,  3 

subacute,  3 

valvular,  430 

wool-sorter's,  116,  117 
Disorders  of  secretion,  835 

of  sensation,  84s 
Dissecting  aneurysm,  470 
Disseminated  neuritis,  662 

sclerosis,  653 
Disturbances  of  consciousness,  576 

of  special  senses,  577 
Diurnal  variations  in  fevers,  7 
Diabetic  coma,  186 
Diabetes  insipidus,  187 

mellitus,  182 
Diacetic  acid,  346 
Diachylon  ointment,  744 
Diagnosis  by  exclusion,  4 
Diagnostic  technic  (stomach),  218 
Diarrhea,  259 

acute,  260,  263 

choleriform,  274 
chronic,  261,  262 

inflammatory,  270 
Diathesis,  2 

hemorrhagic,  177 
uric  acid,  173 
Diazo-reaction,  21,  346 
Dibothriocephalus latus,  278,  288,  289,  290 


INDEX. 


857 


Dicrotic  pulse,  417 
Differential  diagnosis,  4 
Diffused  pericarditis,  419 
Digestive  system,  diseases  of,  200 
Dilated  hypertrophy  (cardiac),  447 
Dilatation,  bronchial,  530 

gastric,  242 

of  the  heart,  449 

of  the  stomach,  242 
Diminished  respiration,  491 
Diphtheria,  82 

antitoxin,  88 

carriers,  83 

laryngeal,  82,  91 

pseudo,  82 
Diphtheroid,  82 
Diphtheritic  endocarditis,  426,  429 

enteritis,  266 

paralysis,  86 
Diplococcus,  Fraenkel's,  127 

intracellularis  meningitidis,  34,  35 
,  pneumoniae,  127 
Dipsomania,  188,  189,  191 
Direct  blood  currents,  414 
Direct  diagnosis,  4 
Discrete  small-pox,  70 
Divers'  paralysis,  659 
Dizziness,  615 
Dracontiasis,  298 
Dracunculus  medinensis,  298 
Dorsointercostal  neuralgia,  669 
Double  pneumonia,  130 
Double  quartan  fever,  43 
Dropsy,  418 

abdominal,  331 

of  the  pleura,  566 

pericardial,  425 
Dry  catarrh,  529 

pericarditis,  420 

rales,  494 
Ductless  glands,  diseases  of,  382 
Duhring's  disease,  757 
Dullness,  48.6 
Duodenal  Ulcer,  234 
Duodenitis,  263 
Dura  mater,  578 
Dural  hemorrhage,  598 
Dysentery,  103,  281 

chronic,  103,  106 
Dysidrosis,  760 


Dyspepsia,  231,  249,  250 

acid,  250 

acute,  224 

atonic,  250 

chronic,  229 

intestinal,  253 

nervous,  250 
Dyspnea,  419,  500 

cardiac,  419 

Eccentric  hypertrophy  (cardiac),  446 
Echinococcus,  288,  290 

of  the  liver,  311 
Ecstasy,  576 
Ecthyma,  756 
Eczema,  733 

ani,  752 

aurium,  750 

barbae,  749 

capitis,  746 

chronic,  737,  744 

crurum,  754 

erythematosum,  734 

faciei,  747 

fissum,  736 

genitalium,  750 

impetiginosum,  735 

intertrigo,  734,  752 

labiorum,  748 

madidans,  736 

marginatum,  786 

mammarum,  752 

narium,  749 

papillomatosum,  737 

palmarum,  753 

palpebrarum,  748 

papulosum,  735 

plantarum,  753 

pustulosum,  735 

rimosum,  736 

rubrum,  736 

sclerosum,  737 

seborrhoicum,  755 

squamosum,  735,  736 

unguium,  754 

universal,  746 

verrucosum,  737 

vesiculosum,  735 
Edema,  418 

angioneurotic,  732 

malignant  anthrax,  117 


858 


INDEX. 


Edema  of  the  glottis,  514 
of  the  lungs,  553 
pulmonary,  553 
Edematous  laryngitis,  514 
Egophony,  499 
Egyptian  chlorosis,  296 
Ehrlisch'  diazo  reaction,  346 

triple  stain,  388 
Elephantiasis,  818 
graecorum,  160 
Embolism,  cerebral,  602 
Empyema,  561,  563,  565 
of  pericardium,  424 
Emphysema,  545 
senile,  546 
vesicular,  545 
Emphysematous  chest,  479 
Emprosthotonos,  113 
Encephalitis,  acute,  607 

suppurative,  607 
Encysted  tumor,  817 
Endarteritis  chronica  deformans,  467 
Endemic  disease,  3 
Endemic  multiple  neuritis,  665 
Endocardial  murmurs,  413 
Endocarditis,  acute,  426 
chronic,  430 
diphtheritic,  429 
exudative,  426 
malignant,  429 
mycotic,  429 
septic,  429 
ulcerative,  429 
Endocardium,  426 
English  cholera,  268 

leprosy,  773 
Engorgement,  pulmonary,  552 
Enteralgla,  256 
Enteric  fever,  16 
Enteritis,  catarrhal,  263 
croupous,  266 
diphtheritic,  266 
membranous,  266 
pseudomembranous,  266 
Enterocolitis,  270 

ulcerative,  270 
Enteromesenteric  fever,  16 
Enterorrhea,  259 
Enumeration  of  blood-cells,  385 
Eosinophiles,  387 
Eosinophilia,  389 


Ephemeral  fever,  11 
Ephidrosis,  835 
Epidemic,  12 

cerebrospinal  fever,  34 
meningitis,  34 

cholera,  95 

diseases,  3 

roseola,  69 

stomatitis,  94 
Epilepsia  gravior,  678 

mitior,  678 
Epilepsy,  678 

Jacksonian,  678 
Epileptic  automatism,  679 

dementia,  706 

imbecility,  706 

insanity,  705 
Epileptiform  convulsions,  569 
Epithelial  casts,  348,  349 
Equino- varus,  638 
Eruptive  fevers,  9 
Erysipelas,  78 

ambulans,  79 

idiopathic,  78 

phlegmonous,  79 
Erythema  caloricum,  725 

induratum,  728 

intertrigo,  725 

multiforme,  725 

nodosum,  727 

scarlatinoides,  726 

toxic,  72s 

traumaticum,  725 

simplex,  725 

solare,  725 

venenatum,  725 
Erythematous  stomatitis,  201 
Erythromelalgia,  670 
Esbach's  test,  341 
Esophageal  obstruction,  216 
Esophagismus,  216 
Esophagitis,  216 
Esophagus,  cancer  of,  217 

diseases  of,  216 

obstruction  of,  216 
Essential  anemia,  396 

paralysis  of  children,  636 
Estivo-autumnal  fever,  48 

parasite,  43 
Euchlorhydria,  220 
Ewald's  test-meal,  219 


INDEX. 


859 


Exaggerated  respiration,  491 
Exanthemata,  9 

table  of,  10 
Exanthematic  typhus,  32 
Exciting  causes  of  disease,  2 
Exophthalmic  goitre,  404 
Expansion  of  the  chest,  480 
Expiration,  480 
External  causes  of  disease,  2 

examination  of  the  stomach,  21! 
Extradural  hemorrhage,  598 
Exudative  endocarditis,  426 

Facial  paralysis,  673 
False  aneurysm,  470 

croup, 82 

measles,  69 
Falx,  578 
Famine  fever,  38 
Farcy,  93,  94 
Fatty  casts,  349 

heart,  457 

stools,  260 
Favus,  794 
Febricula,  11 
Febris  recurrens,  38 
P^eeble-mindedness,  acquired,  718 
Fehling's  test,  343 
Festinating  gait,  570 
Fetid  bronchitis,  529 
Fever  and  ague,  41 

anopheles,  41 

aphthous,  94 

autumnal,  16 

bilious,  48 

malignant,  53 
remittent,  48,  53 

blackwater,  52 

blisters,  761 

break-bone,  58 

catarrhal,  12 

cerebral,  581 

cerebrospinal,  34 

chillsand,  41 

congestive,  49 

contagious,  32 

dandy,  58 

degrees  of,  6 

double  quartan,  43 

enteric,  16 

enteromesenteric,  16 


Fever,  ephemeral,  11 

epidemic  cerebrospinal,  34 
estivo-autumnal,  48 
famine,  38 
gastric,  16,  224 
Gibraltar,  40 
glandular,  162 
hemoglobinuric,  52 
intermittent,  45 
jail,  32 
lung,  127 

malignant  intermittent, 
malarial,  57 

pernicious,  49 
Malta,  40 
marsh,  41,  48 
Mediterranean,  40,  53 
mosquito,  41 
Neapolitan,  40 
nervous,  16 
paratyphoid,  31 
pernicious  malarial,  49 
petechial,  34 
putrid,  32 
quartan,  43 
quotidian,  43 
relapsing,  38 
remittent,  49 

bilious,  53 

malaria,  48 

malignant,  49 
rheumatic,  121 
rock,  40 
sailors',  53 
scarlet,  59 
seven-day,  38 
ship,  32 

simple  continued,  11 
spirillum,  38 
splenic,  116 
spotted,  32,  34 
swamp,  41 
tertian,  43 
types  of,  7 
typhoid,  16 
typho-malarial,  48 
typhus,  32 
undulant,  40 
yellow,  53>  57 
Fevers,  s 

continued,  7 


86o 


INDEX. 


Fevers,  diurnal  variations  of,  7 

eruptive,  9 

general  treatment  of  all,  8 

immunity  in,  1 1 

incubation  period  of,  9 

intermittent,  7 

jaundice  in,  1 1 

remittent,  7 

types  of,  7 
Fibrinous  bronchitis,  535 
Fibroid  heart,  454 

pneumonia,  559 
Fibrosis,  arteriocapillary,  467 
Fibrous  myocarditis,  454 
Fibrinous  pneumonia,  127 
Fibroid  phthisis,  152 
FUaria,  292,  294,  298 

Bancroft!,  294 

medinensis,  298 

noctuma,  294 

sanguinis  hominis,  292,  294,  818 
Filariasis,  296,  297 
Fish-skin  disease,  809 
Floating  kidney,  377 
Flirx,  alvine,  259 

bloody,  103 
Focal  symptoms,  591 
Folie  circulaire,  696,  707 
Follicular  stomatitis,  202 
Foot  and  mouth  disease,  92 

perforating  ulcer  of  the,  575 
Foot-drop,  663 
Foul  breath,  209 
Fowler's  test  for  urea,  336 
Fralnkel's  diplococcus,  127 
Frankel  treatment,  651 
Freckles,  803 
Fremitus,  481 
French  measles,  69 
Friction  fremitus,  481 
Friedlander 's  pneumococcus,  128 
Friedreich's  ataxia,  657 

disease,  656 
Full  pulse,  417 
Functional  affections  of  the  heart,  459 

endocardial  murmurs,  414 

obstruction  of  the  esophagus,  216 
Furuncle,  780 
Furunculosis,  780 
Fusiform  aneurysm,  470 


Gait,  570 

Gall-bladder,  acute  inflammation  of,  321 

diseases  of,  315 
Gall-stones,  317 
Galloping  consumption,  142 
Gangrene,  spontaneous,  575,  688 

of  the  lung,  129 
Gangrenous  pancreatitis,  322 

stomatitis,  205 
Gastralgia,  246 
Gastrectasia,  242 
Gastrectasis,  242 
Gastric  cancer,  238 

carcinoma,  238 

catarrh,  224 
chronic,  229 

dilatation,  242 

fever,  16,  224 

hemorrhage,  245 

indigestion,  249 

insufficiency,  250 

irritation,  250 

ulcer,  234 

vertigo,  616 
Gastritis,  acute,  224 

chronic,  229 

simple,  224 

toxic,  225,  227 
Gastrodynia,  247 
Gastroenteric  type  of  pernicious  malarial 

fever,  50 
Gastrointestinal     symptoms     in     cardiac 

disease,  419 
Gastroptosia,  243 
Gastrorrhagia,  245 
General  nervous  diseases,  675 

paralysis  of  the  insane,  714 

paresis,  714 

symptomatology  of    diseases  of    the 
respiratory  tract,  500 

treatment  of  all  fevers,  8 
German  measles,  69 
Gibraltar  fever,  40 
Gin-drinkers'  liver,  305 
Glanders,  93 
Glandular  fever,  162 
Globus  hystericus,  683 
Glossitis,  207 

Glosso-labio-laryngeal  paralysis,  639 
Glossy  skin,  574 


INDEX. 


86 1 


Glottis,  edema  of,  514 

spasm  of,  518 
Glycosuria,  182,  184 
Gmelin's  test  for  bile,  345 
Goitre,  exophthalmic,  404 
Gonagra,  170 
Gout,  169 
Gouty  kidney,  359 
Graefe's  sign,  405 
Grand  mal,  le,  678 
Granular  casts,  348,  349 

kidney,  359,  362 
Gravel,  368 
Graves'  disease,  404 
Green  sickness,  392 

stools,  260 
Grey  hepatization,  129 
Grip,  12 
Gripes,  256 
Grutum,  836 

Guinea-worm  disease,  298 
Gummatous  syphiloderm,  833 
Giinzburg's  test,  221 
Gurgling  rale,  496 

Hair,  hypertrophy  of,  818 
Hallucination,  693,  711 
Hallucinatory  melancholia,  696 
Hammerschlag 's  method,  384 
Hard  pulse,  418 
Harsh  respiration,  493 
Hay  asthma,  537 

fever,  537 
Headache,  619 
Heartburn,  249 
Heart,  abscess  of,  453 

action  of,  412 

dilatation  of,  449 

fatty,  457 

fibroid,  454 

functional  affections  of  the,  459 

hypertrophy  of,  446 

irritable,  459 

murmurs,  413 

neuralgia  of,  464 

palpitation  of  the,  459 

paroxysmal  rapid,  461 

quick,  461 

rapid,  461 

sounds,  411 
Heat  and  nitric  acid  test  for  albumin,  341 


Heat  exhaustion,  198 
Heat  stroke,  198 
Heberden's  nodosities,  168 
Heller's  test  for  albumin,  341 

test  for  blood,  344 
Hematemesis,  245 
Hematidrosis,  836 
Hematuria,  344 

malarial,  52 
Hematogenous  jaundice,  316 
Hemianesthesia,  573 
Hemic  murmurs,  414 
Hemichorea,  676 
Hemicrania,  619 
Hemiplegia,  568 
Hemoconien,  387 
Hemoglobin,  383 
Hemoglobinuria,  344 

malarial,  52 
Hemoglobinuric  fever,  52 
Hemophilia,  177 
Hemoptysis,  246,  549 

bronchial,  549 

bronchopulmonary,  549 
Hemorrhage,  cerebral,  595 

dural,  598 

gastric,  245 

ocult,  24s 
Hemorrhagic  diathesis,  177 

icterus,  304 

measles,  67 

pancreatitis,  322 

type  of  pernicious  malarial  fever,  50 
Hepatic  calculi,  317 

cancer,  313 

colic,  317 
Hepatitis,  acute,  302 

interstitial,  305 

parenchymatous,  302,  304 

suppurative,  302 
Hepatization  in  pneumonia,  128 
Hereditary  ataxia,  656 

ataxic  paraplegia,  656 

syphilis,  833 
Herpes  circinatus,  785 

facialis,  761 

gestationis,  757,  762 

labialis,  761 

preputialis,  762 

progenitalis,  762 

simplex,  761 


862 


INDEX. 


Herpes  tonsurans,  788 
maculosus,  777 

zoster,  666 
Hidebound  disease,  820 
Hirsuities,  818 
Hives,  728 
Hob-nailed  liver,  305 
Hodgkin's  disease,  401 
Hook-worm  disease,  296 
Host,  287 

intermediate,  287 
Huntington's  chorea,  676 
Hutchinson's  teeth,  201 
Hyaline  casts,  349 
Hydatid  cyst  of  the  liver,  311 
Hydrenia,  389 
Hydroa,  757 
Hydrocephalic  cry,  582 
Hydrocephalus,  acute,  582,  585,  622 

acquired,  622 

chronic,  623 

congenital,  623 
Hydrochloric  acid,  tests  for,  221 
Hydronephrosis,  371 
Hydropericardium,  425 
Hydroperitoneum,  331 
Hydrophobia,  114 
Hydropneumothorax,  566 
Hydrosis,  835 
Hydrothorax,  566 
Hyperacidity,  220 
Hyperchlorhydria,  220 
Hyperemia  of  the  skin,  724 

renal,  350 

spinal,  625 
Hyperesthesia,  572 
Hypertrichosis,  818 

Hypertrophic  cirrhosis  of  the  liver,   306, 
307,  308 

pachymeningitis,  627 
Hyperresonance,  486 
Hypertrophy,  compensatory,  431 

of  the  hair,  818 

of  the  heart,  446 

of  the  nails,  819 

of  the  skin,  803 

of  the  tonsils,  215 

pseudo-muscular,  644 
Hypochlorhydria,  220 
Hypochondriac  melancholia,  696 
Hypochondriasis,  683 


Hypostatic  congestion,  552 

Hypotonia,  650 

Hysteria,  683 

Hy steroidal  convulsions,  569 

Hyperidrosis,  835 

Ichthyosis,  809 

hystrix,  810 

lingualis,  209 

nigricans,  810 

simplex,  810 

vera,  809 
Icterus,  315 

hemorrhagic,  304 

neonatorum,  316 
Idiocy,  694 

Idiopathic  anemia,  396 
Idrosis,  835 
Ileocolitis,  263 
Illusion,  693 
Immediate  auscultation,  487 

percussion,  482 
Immunity  in  fevers,  1 1 
Impetigo  contagiosa,  755 
Impetiginous  syphilis,  832 
Incipient  phthisis,  148 
Incubation  period  of  fevers,  3,  9 
Indicanuria,  346 
Indigestion,  acute,  253 

chronic,  253 

gastric,  249 

intestinal,  253 
Indirect  blood  currents,  414 
Infantile  meningeal  hemorrhage,  598 

palsy,  636  -« 

scurvy,  179 

spinal  paralysis,  636 
Infants,  constipation  of,  259 
Infectious  diseases,  2,  5 
Inflammation  of  the  bowels,  263 

of  the  peritoneum,  326 

of  the  skin,  725 
Inflammatory  diarrhea,  270 

rheumatism,  121 
Influenza,  12,  526 
Inherited  predisposition,  2 
Insane,  general  paralysis  of  the,  714 
Insanity,  694,  699 

alternating,  708 

chronic  delusional,  712 

circular,  707 


INDEX. 


863 


Insanity,  classification  of,  694 

definition  of,  694,  699 

delusional,  709 

epileptic,  705 

Kahlbaum's,  708 

paralytic,  718 
Insolation,  198 
Inspection,  479 

of  precordium,  408 
Inspiration,  480 
^     Insufficiency,  aortic,  433 

gastric,  250 

mitral,  431 

pulmonary,  438 

tricuspid,  438 
Intentional  tremor,  654 
Intermediate  host,  287 
Intermittent  fever,  7,  45 
malignant,  49 

pulse,  417 

tetanus,  689 
Internal  examination  of  the  stomach,  219 

causes  of  disease,  i 
Interstitial  hepatitis,  305 

myocarditis,  chronic,  454 

nephritis,  chronic,  359,  362 

pneumonia,  chronic,  559 
Intestinal  anthrax,  117 

catarrh,  263 

colic,  256 

dyspepsia,  253 

indigestion,  253 

invagination,  283 

obstruction,  282 

obstruction,  acute,  286 

obstruction,  chronic,  286 

parasites,  287 

torpor,  257 
Intestine,  tubercular  ulcer  of,  17 

typhoid  ulcer  of,  17 
Intestines,  diseases  of,  253 
Intoxications,  188 
Intracranial  tumor,  609 
Intussusception,  283,  286 
Invagination,  intestinal,  283 
Irregular  pulse,  417,  463 
Irritable  heart,  259 
Irritation,  gastric,  250 
Itch,  the,  797 
Itch-mite,  797 


Itching,  84s 

Ivy  poisoning,  778 

Jacksonian  epilepsy,  678 
Jaffe's  test  for  indican,  346 
Jail  fever,  32 
Jaundice,  315 

catarrhal,  316 

hematogenous,  316 

in  fevers,  1 1 

malignant,  304 

non-obstructive,  316 
Jaw-jerk,  572 
Johnson's  test  for  albumin,  341 

for  sugar,  342 
Jugular  pulsation,  409 

Kahlbaum's  insanity,  708 
Kakke,  665 
Katatonia,  708 
Keloid,  823 

of  Addison,  820 

of  Alibert,  823 
Keratosis  pilaris,  817 
Kernig's  sign,  3  5.  36 
Kidney,  amyloid,  364 

cirrhotic,  359,  362 

congestion  of,  350 

contracted,  359,  362 

floating,  377 

gouty,  359 

granular,  359,  362 

inflammation  of,  352,  355,  539 

lardaceous,  364 

large  white,  355,  362 

movable,  377 

sclerosis  of,  359 

small  red,  362,  359 
white,  362 

surgical,  366 

tuberculosis  of,  372 

wandering,  377 

waxy,  364 
Kidneys,  diseases  of,  350 
Klebs-Loeffler  bacillus,  82,  83,  87 
Koch's  bacillus,  95 

bacillus  of  tuberculosis,  141 
Koplik's  spots  in  measles,  66 
Knee-jerk,  571 
Kummerfeld's  lotion,  768 


864 


INDEX. 


La  grippe,  12 
Lab  ferment,  test  for,  223 
Laced-ofI  liver,  299 
Lactic  acid,  tests  for,  222 
Landry's  paralysis,  645 
Lardaceous  kidney,  364 

liver,  309 
Large  lymphocyte,  386 

white  kidney,  355,  362 
Laryngeal  diphtheria,  82,  91 

muscles,  paralysis  of,  674 

phthisis,  522 

rales,  495 

resonance,  490 
Laryngismus  stridulus,  518 
Laryngitis,  acute  catarrhal,  511 

chronic,  520 

edematous,  514  .       . 

spasmodic,  516,  518 

syphilitic,  521 

tuberculous,  522 
Larynx,  diseases  of,  511 
Lateral  and  posterior  sclerosis,  combined, 

652 
Lateral  sclerosis,  657 

amyoptrophic,  641,  646 

primary,  646 
Laveran's  Plasmodium,  41 
Legal 's  test  for  acetone,  345 
Leichtenstern's     pulmono-hepatic    angle, 

219 
Lentigo,  803 
Lepra,  773 
Leprosy,  160 

English,  773 
Leptomeningitis,  579 

acute,  581 

spinal,  629 
Lesions,  i 

of  the  skin,  722,  723 
Leube  Reigel  test-meal,  219 
Leucin,  339 
Leukemia,  398 
Leukocytes,  polynuclear,  386 
Leukocythemia,  398 
Leukocytosis,  388 
Leukoderma,  819 
Leukopenia,  389 
Leukoplakia,  207 

buccalis,  209 
Lieben's  iodoform  test,  223 


Lichen  planus,  762 

ruber  acuminatus,  763 

scrofulosus,  764 

simplex,  735 

tropicus,  839 

urticatus,  730 
Lienteric  stools,  260 
Lightning  pains,  574 
Lipemia,  390 

Lipomatosis  luxurians  muscularis,  644 
Lipomatous  muscular  atrophy,  644 
Lithemia,  173 
Lithiasis,  173 
Lithuria,  337 
Liver,  abscess  of,  302 

acute  yellow  atrophy  of,  304 

albuminoid,  309 

amyloid,  309 

atrophic  cirrhosis  of,  306 

atrophy  of,  304 

carcinoma  of,  313 

cirrhosis  of,  305,  306 

congestion  of,  300 

corset,  299 

diseases  of,  298 

echinococcus  of,  311 

gin-drinker's,  305 

hob-nailed,  305 

hydatid  cyst  of,  311 

hypertrophic  cirrhosis  of,  306 

laced-off,  299 

lardaceous,  309 

location  of,  298 

sarcoma  of,  314 

spots,  793,  804 

syphilis  of,  312 

torpid,  300 

waxy,  309 
Lobar  pneumonia,  127 
Lobular  pneumonia,  555 
Localization,  cerebral,  589 

of  cerebral  hemorrhage,  597 

spinal,  633 
Lockjaw,  112 

Locomotor  ataxia,  648,  657 
Lotio  alba,  768 
Lousiness,  801 
Lucid  interval,  694 
Ludwig's  angina,  206 
Lumbago,  164,  165 
Lumboabdominal  neuralgia,  669 


INDEX. 


865 


Lumbodynia,  165 
Lung,  abscess  of,  129 

gangrene,  of  129 
Lung-fever,  127 
Lungs,  cirrhosis  of  the,  559 

congestion  of,  552 

diseases  of,  545 

edema  of,  55,3 
Lupoid  sycosis,  773 
Lupus  erythematodes,  824 

erythematosus,  824 

exedens,  826 

exulcerans,  826 

non-exedens,  824 

sebaceus,  824 

vorax,  826 

vulgaris,  826 
Lymphadenoma,  401 
Lymphatic  anemia,  401 

leukocythemia,  398,  400 

lymphatism,  402 
Lymphocytes,  large,  386 

small,  386 

transitional  forms  of,  386 
Lysis,  definition  of,  4 
Lyssa,  114 
Lyssophobia,  116 

Macrocythemia,  389 

Macular  syphiloderm,  830 

Macules,  723 

Madness,  699 

Magnesium  test  for  phosphates,  339 

Malaria,  41,  57 

intermittent,  45 

pernicious,  49 

typho-,  24 
Malarial  cachexia,  52 

fevers,  57 

hematuria,  52 

hemoglobinuria,  52 

types  of  infections,  44 
Malignant  anthrax  edema,  117 

cholera,'  95 

endocarditis,  429 

intermittent  fever,  49 

jaundice,  304 

measles,  67 

pustule,  116,  117 

quinsy,  82 

remittent  fever,  49 

55 


Malignant  scarlet  fever,  62 

small-pox,  71 
Malta  fever,  40 
Mania,  699 

delusional,  709 
reasoning,  712 
Mania-a-potu,  188,  190 
Marsh  fever,  41,  48 
Mast  cells,  387 
Measles,  66 
Mediate  auscultation,  487 

percussion,  482 
Medicine,  practice  of,  defined,  i 
Mediterranean  fever,  40,  53 
Megaloblasts,  387 
Megalomania,  716 
Megrim,  619 
Melancholia,  696 
agitata,  696 
attonita,  696 
delusional,  709 
simplex,  696 
Melanemia,  390 
Melanoderma,  80s 
Melasma  melanoderma,  805 
Melena,  260 
Melituria,  182 
Membranous  angina,  82 
bronchitis,  535 
croup, 82 
enteritis,  266 
Meningeal  hemorrhage,  598 
Meningitis,  579 
acute,  581 
basilar,  585 

epidemic  cerebrospinal,  34 
spinal,  629 
tubercular,  585,  612 
Meniere's  disease,  615 
Mensuration,  482 
Mental  diseases,  693 
Mercurial  stomatitis,  206 
Metallic  tinkling,  497 
Metastatic  parotitis,  81 
Microblasts,  387 
Micrococcus,  Bruce's,  40 

melitensis,  40 
Microcythemia,  389 

Microscopic  examination  of  the  blood,  3< 
of  the  sputum,  503 
of  the  stomach-contents,  224 


866 


INDEX. 


Microscopic  examination  of  the  urine,  347 
Microsporon  furfur,  793 
Migraine,  619 
Miliaria,  839 

alba,  839 

crystallina,  838 

papulosa,  840 

rubra,  839 

vesiculosa,  840 
Miliary  pustular  syphiloderm ,  831 

tuberculosis,  acute,  142 
Milium,  816 
Mind  center,  590 
Mistura  ferri  acida,  767 
Mitral  insufficiency,  43 1 

obstruction,  439 

regurgitation,  431,  434,  43 5 

stenosis,  439,  435 
Moebius'  sign,  405 
Moist  friction  sounds,  497 

rales,  495 
Molluscum  contagiosum,  814 

epitheliale,   814 

sebaceum,  814 
Monanesthesia,  573 
Monomania,  712 
Monoplegia,  568,  569 
Moore's  test  for  sugar,  342 
Morbid  anatomy,  definition  of,  3 
Morbus  maculosus  Werlhofii,  180 
Morbilli,  66 
Morphea,  820 
Mosquito  fever,  41 
Mosquitoes,  41,  42,  46 
Moth,  804 
Motor  aphasia,  613,  614 

area,  589 

phenomena,  568 

power  of  the  stomach,  224 
Mouth,  diseases  of,  200 
Movable  kidney,  377 
Mucous  catarrh,  529 

patches,  831 

stools,  260 
Mucus  in  urine,  340 
Muguet,  204 
MuUer's  blood-dust,  387 
Multiple  neuritis,  662 
endemic,  665 

sclerosis  of  the  brain  and  cord,  653 
Mumps,  80 


Murmurs,  anemic,  414 

heart,  413 

hemic,  414 
Muscles,  atrophy  of,  575 

degeneration  of,  575 

paralysis  of  laryngeal,  674 
Muscular  atrophy,  chronic  spinal,  641 
lipomatous,    644 
progressive,  641 

paralysis,  pseudohypertrophic,  644 

rheumatism,  164 

sense,  574 

center  for,  590 
Mutacismus,  709 
Mutism,  709 
Myalgia,  164 
Mycosis  intestinalis,  117 
Mycotic  endocarditis,  429 
Mydriasis,  577 
Myelitis,  acute,  631 

of  anterior  horns,  636 
Myelocytes,  387 

Myelogenic  leukocythemia,  398,  400 
Myocarditis,  acute,  453 

chronic,  454 

interstitial,  454 

fibrous,  454 
Myocardium,  diseases  of  the,  446 
Myosis,  577 
Myxedema,  406 

Naevus  pilosus,  818 
Nails,  atrophy  of,  821 

hypertrophy  of,  819 
Nasal  catarrh,  acute,  505 
chronic,  508 
diphtheria,  92 
passages,  diseases  of,  505 
Nauheim,  treatment,  453 
•Neapolitan  fever,  40 
Nematodes,  291 
Nephritis,  acute,  362 

acute  croupous,  352 
desquamative,  352 
•    paranchymatous,  352 

tubal,  352 
catarrhal,  350 
chronic,   362 
croupous,  3SS 
desquamative,  355 
interstitial,  359,  362 


INDEX. 


867 


Nephritis,  parenchymatous,  3.55 
suppurative,  366 
tubal,  355 
NephroUthiasis,  368 
Nephroptosis,  377 
Nerve-cell,  588 

Nerve-supply  of  the  dura,  578 
Nerves,  diseases  of,  660 
Nervous  diseases,  general,  675 

dyspepsia,  250 

exhaustion,  687 

fever,  16 

prostration,  687 

system,  diseases  of,  568,  578 

vertigo,  616 
Nettle-rash,  728 
Neuralgia,  574,  667 

cervico-brachial,  669 

cervico-occipital,  668 

dorso-intercostal,  669 

lumbo-abdominal,  669 

of  the  fifth  nerve,  668 

of  the  heart,  464 

of  the  stomach,  246 

red,  670 

trifacial,  668 
Neurasthenia,  686,  687 
Neuritis,  degenerative,  662 

disseminate,  662 

endemic  multiple,  665 

multiple,  662 

optic,  577 

peripheral,  662 

simple,  660 
Neuroglia,  588 
Neuron,  588 
Neuroses,  occupation,  690 

professional,  690 
Neutrophiles,  polymorphonuclear,  386 
New  growths  of  the  skin,  823 
Nocturnal  tetany,  690 
Noma,  205 

Non-obstructive  jaundice,  316 
Normal  blood,  382 

pulmonary,  resonance,  484 

vesicular  murmur,  489 

vocal  resonance,  490,  498 
Normoblasts,  387 

Nucleated  red  blood-cells,  387,  389 
Nutritive  disturbances,  575 
Nystagmus,  577 


Obstruction,  aortic,  440 

esophageal,  216 

intestinal,  282 
acute,  286 
chronic,  286 

mitral,  439 

of  the  common  duct,  319 

of  the  cystic  duct,  319 

pulmonary,  442 

tricuspid,  244 
Occlusion  of  the  cerebral  vessels,  602 
Occult  blood,  24s 

hemorrhage,  245 
Occupation  neuroses,  690 
Ocular  vertigo,  615 
Oidium  albicans,  204 
Oinomania,  188,  189,  191 
Oligochromemia,  388 
Oligocythemia,  388 
Oliguria,  334 
Onomatomania,  709 
Onychauxis,  819 

Open  air  treatment  for  pneumonia,    137 
Opisthotonos,  113 
Optic  atrophy,  577 

neuritis,  577 
Organic  dementia,  721 

endocardinal  murmurs,  414 

obstruction  of  the  esophagus,  216 
Oriental  plague,  in 
Orthopnea,  500 
Orthotonos,  113 
Oxalate,  calcium,  338,  340 
Oxalates,  339 
Oxaluria,  339 

Oxyuris  vermicularis,  291,  292,  293 
Ozena,  508,  509 

Pacchionian  granulations,  579 
Pachymeningitis,  579 

externa,  579 

hypertrophic,  627 

interna,  579 

spinal,  627 

syphilitica,  580 
Pain  in  precordial  region,  419 
Palpation,  480 

of  the  precordium,  409 
Palpitation  of  the  heart.  418,  459 
Palsy,  Bell's,  673 

infantile,  636 


868 


INDEX. 


Palsy,  shaking,  691 

wasting,  641 
Pancreas,  cancer  of,  324 

cysts  of,  324 

diseases  of,  322 
Pancreatic  calculi,  325 
Pancreatitis,  acute,  322 

chronic,  322 
Pandemic  diseases,  3 
Papillitis,  577 
Papular  syphiloderm,  830 
Papules,  723 

Paradoxic  contraction,  572 
Paragraphia,  613,  614 
Paralysis,  568 

acute  ascending,  645 

agitans,  691 

alcoholic,  662 

amyothrophic ,  657 

atrophic,  of  children,  636 

bulbar,  639 

chronic  progressive  bulbar,  639 

diver's,  659 

essential,  of  children,  636 

facial,  673 

general,  714 

glosso-labio-laryngeal,  639 

infantile  spinal,  636 

of  laryngeal  muscles,  674 

of  the  insane,  general,  714 

pseudo-hypertrophic  muscular,  644 

spastic  spinal,  646 
Paralytic  insanity,  718 
Paranephritis,  372 
Paranesthesia,  573 
Paranoia,  712 
Paraphasia,  613 
Paraplegia,  568,  569 

ataxic,  652,  657 

hereditary  ataxic,  656 
Parasite  of  malaria,  41,  43 
Parasites,  287 

intestinal,  287 

in  the  blood,  390 
Parasitic  diseases  of  the  skin,  785 

stomatitis,  204 
Paratyphoid  fever,  31 
Parenchymatous  hepatitis,  302,  304 

nephritis,  acute,  352 
chronic,  355,  362 
Paresis,  714 


Paresis,  general,  714 
Paresthesia,  572,  574 
Paretic  dementia,  714 
Parkinson's  disease,  691 
Parotitis,  80 

•     secondary,  81 
Paroxysmal  rapid  heart,  461 
Partial  cerebral  anemia,  602 

dementia,  721 
Pasteur  treatment,  116 
Patellar  reflex,  571 
Pathogenesis,  definition  of,  i 
Pathognomonic  symptoms,  3 
Pathology,  i 
Pectoriloquy,  498 
Pediculosis,  801 

capitis,  801 

corporis,  801 

pubis,  801 

vestimenti,  801 
Pediculus  capitis,  801 
Pediculus  pubis,  802 
Peliosis  rheumatica,  181 
Pellagra,  197 

Pemphigoid  syphilide,  833 
Pemphigus,  758 

foliaceus,  759 

hemorrhagicus,  758 

malignus,  759 

pruriginosus,  759 

vegetans,  759 

vulgaris,  759 
Pepsin,  test  for,  223 
Peptic  ulcer,  234 
Peptone  in  the  urine,  346 

test  for,  223,  346 
Percussion,  482 

of  the  precordium,  410 
Perforating  ulcer  of  the  foot,  575 
Pericardial  dropsy,  425 

murmurs,  413 
Pericarditis,  acute,  419 

chronic,  424 
Pericardium,  diseases  of  the,  419 

empyema  of,  424 
Perinephritic  abscess,  372 
Period  of  compensation,  431 

of  incubation,  definition  of,  3 
Peripheral  neuritis,  662 
Peritoneum,  diseases  of,  326 

inflammation  of,  326 


INDEX. 


869 


Peritonitis,  286,  326 

acute,  327 

chronic,  328 
Perityphlitis,  277 
Pernicious  anemia,  396 

malarial  fever,  49 
Pertussis,  118 
Pes  cavus,  638 
Petechial  fever,  34 

typhus,  34,  32 
Petit  mal.  le,  679 

Pettenkofer's  test  for  bile-pigment,  345 
Phantom  tumor,  685 
Pharyngitis,  acute  catarrhal,  210 

chronic,  211 

glandular,  2 1 1 

phlegmonous,  213 
Pharynx,  diseases  of,  210 

ulceration  of,  212 
Phenomena,  motor,  568 

sensory,  572 
Phenyl-hydrazin  test,  343 
Phlegmonous  erysipelas,  79 

pharyngitis,  213 
Phosphate  ammonio  magnesium,  337 
■Phosphates,  337,  338,  339 
Phosphaturia,  338 
Phosphoridrosis,  836 
Phthiriasis,  801 
Phthisinoid  chest,  479 
Phthisis,  141 

caseous,  144 

catarrhal,  144 

chronic,  146,  148 
ulcerative,  148 

fibroid,  397 

fiorida,  144,  146 

incipient,  148 

laryngeal,  522 

pneumonic,  141,  144 

pulmonalis,  141 

tubercular,  141 
Physical  diagnosis,  408,  475 

signs,  definition  of ,  3 
Piano-player's  cramp,  690 
Pityriasis,  841 

maculata  et  circinata,  777 

rosea,  777 

versicolor,  793 
Plague,  III 

Bubonic,  1 1 1 


Plague,  Oriental,  1 1 1 
Plasmodium,  Laveran's,  41 

malariae,  41,  43    45 

vivax,  45 
Plastic  bronchitis,  535 

endocarditis,  426 
Pleura,  diseases  of  the,  560 

dropsy  of,  566 
Pleural  cavity,  air  in  the,  566 

rales,  497 
Pleurisy,  560 
Pleuritis,  560 
Pleurodynia,  164,  165 
Pleuro-pneumonia,  130 
Pleurosthotonos,  113 
Pneumococcus,  Friedlander's,  i2i 
Pneumonia,  alcoholic,  133 

apical,  134 

apyretic,  134 

aspiration,  134 

basal,  134 

bilious,  133 

caseous,  144 

catarrhal,  555 

central,  134 

chronic  catarrhal,  144 
interstitial,  152,  539 

creeping,  134 

croupous,  127 

double,  130 

ether,  134 

fibrinous,  127 

fibroid,  559 

in  children,  134 

intermittent,  133 

in  the  aged,  134 

latent,  134 

lobar,  127 

lobular,  555 

malarial,  133 

massive,  134 

migratory,  134 

of  the  insane,  134 

post-operative,  134 

terminal,  134 

traumatic,  134 

typhoid,    133 
Pneumonic  phthisis,  144,  141 
Pneumonitis,  152 
Pneumothorax,  566 
Podagra,  169 


870 


INDEX. 


Poikilocytosis,  389 
Poisons  and  antidotes,  227 
Poliomyelitis  anterior  acuta,  636 

chronic,  641 
Polyneuritis,  662 
Polynuclear  leukocytes,  386 
Polymorphonuclear  neutrophiles,  386 
Polyuria,  187,  334 
Pomphi,  723 
Pompholyx,  760 
Pons  hemorrhage,  598 
Position  of  apex-beat,  408 
Postepileptic  mania,  706 
Posterior  sclerosis,  combined  lateral  and, 
652 

spinal  sclerosis,  648 
Practice  of  medicine,  definition  of,  i 
Precordium,  408 
Predisposing  causes  of  disease,  2 
Pre- epileptic  mania,  706 
Prickly  heat,  839 
Primary  anemia,  390 

spastic  paraplegia,  657 
Proctitis,  281 
Prodromes,  3 

Professional  neuroses,  690 
Proglottides,  290 
Prognosis,  definition  of,  4 
Progressive  bulbar  paralysis,  chronic,  639 

muscular  atrophy,  641,  657 

pernicious  anemia,  396 
Propeptone,  test  for,  223 
Prosopalgia,  668 
Proteus  vulgaris,  277 
Protoplasmic  processes,  588 
Prurigo,  764 
Pruritus,  845 

ani,  846 
Pseudoangina,  466 
Pseudodiphtheria,  82 
Pseudohydrophobia,  116 
Pseudohypertrophic  muscular  paralysis, 

644 
Pseudoleukemia,  401 

splenic,  402 
Pseudoleukocythemia,  401 
Pseudomembranous,  enteritis,  266 

pachymeningitis,  627 
Pseudomuscular  hypertrophy,  644 
Pseudotabes,  662 
Psoriasis,  773 


Psoriasis,  circinata,  774 

diffusa,  775 

guttata,  774 

gyrata,  775 

nummularis,  774 

palmaris  et  plantaris,  775 

punctata,  774 

unguium,  775 
Psychalgia,  696 
Ptyalism,  mercurial,  206 
Pulmonary  edema,  553 

engorgement,  552 

insufficiency,  438 

obstruction,  442 

regurgitation,  438 

stsnosis,  442 

tuberculosis,  143,  141 
treatment  of,  153 
Pulse,  416 

in  fever,  7 

irregularity  of  the,  463 

relation  of,  to  temperature,  8 
Pulsus  paradoxus,  417 
Pupil,  Argyll-Robertson,  649 
Pupils,  unequal,  577 
Purging,  259 
Purpura,  180 

haemorrhagica,  180 

scorbutic,  178 

simplex,  180 

urticans,  180 
Purulent  stools,  260 
Pus  in  urine,  345 
Pus-casts,  349 
Pustular  syphiloderm,  83 1 
Pustule,  malignant,  ir6,  117 
Pustules,  723 
Putrid  fever,  32 

sore  mouth,  203 
Pyelitis,  366 
Pyelonephritis,  366 
Pyelonephrosis,  366 
Pyloric  obstruction,  242 

stenosis,  242 
Pyrexia,  degrees  of,  6 
Pyrosis,  249 
Pyuria,  345 

Quantitative  tests  for  albumin,  34 
for  glucose,  343 
for  urea,  336 


INDEX. 


871 


Quantitative  tests  for  uric  acid,  338 
Quartan  fever,  43 

Ijarasite,  43 
Quick  heart,  461 
Quinsy,  213 

malignant,  82 
Quotidian  fever,  43 

Rabies,  114 

Rachitic  chest,  479 

Rachitis,  175 

Rales,  494 

Ralfe's  test  for  peptone,  346 

Rapid  heart,  461 

Rashes,  vaccination,  77 

Rate  of  absorption,  224 

of  respiration,         501 
Raynaud's  disease,  575,  688 
Reaction,  Cammidge's,  325 

Desmoid,  of  Sahli,  223 

Diazo,  346 

of  degeneration,  636 

of  the  blood,  383 

of  the  stomach-contents,  220 

Sahli 's  desmoid,  223 

Widal's,  23 
Reasoning  mania,  712 
Rectitis,  281 
Rectum,  catarrh  of,  281 
Red  blood-cells,  387 

hepatization,  129 

neuralgia,  670 

stools,  260 
Reflexes,  571 
Regurgitation,  aortic,  433 

mitral,  43 1 

pulmonary,  438 

tricuspid,  438 
Relapsing  fever,  38 
Relation  of  pulse  to  temperature,  7 
Remittent  fever,  48 
bilious,  48,  53 
malignant,  49 
Renal  calculi,  368 

colic,  368 

hyperemia,  350 
Rennet,  test  for,  223 
Respiration,  Cheyne- Stokes,  458,  576 
Respiratory  movement,  480 

percussion,  475 

system,  diseases  of,  475 


Retrocedent  gout,  171 
Rheumatic  fever,  121 
Rheumatism,  acute  articular,  121 

chronic  articular,  163 

inflammatory,  121 

muscular,  164 
Rheumatoid  arthritis,  167 
Rhinitis,  acute,  505 

atrophic,  508 

chronic,  508 

hypertrophic,  508 
Rhinophyma,  770 
Rhus  poisoning,  778 
Rhythm,  respiratory,  492 
Rickets,  175 
Ringworm  of  the  beard,  791 

of  the  body,  785 

of  the  nails,  786 

of  the  scalp,  788 
Risus  sardonicus,  113 
Roberts'  test  for  sugar,  343 
Rock  fever,  40 
Romberg's  symptom,  649 
Rosacea,  769 
Rose,  the,  78 

cold,  537 
Roseola,  epidemic,  69 
Rotheln,  69 
Round  ulcer,  234 

worms,  291 
Rovsing's  sign,  280 
Rubella,  69 
-Rubeola,  66 
Rupia,  832 

Ruptured  compensation,  431 
Rush  of  blood  to  the  head,  592 

Sacculated  aneurysm,  470 
Sahli's  desmoid  reaction,  223 
Sailor's  fever,  53 
Salt  rheum,  733 
Sarcoma  of  the  liver,  314 
Sarcopties  scabiei,  797 
Scabies,  797 
Scall,  733 
Scarlatina,  59 

miliaris,  60 
Scarlatinal  arthritis,  65 
Scarlet  fever,  59 
Schonlein's  disease,  181 
Schott  treatment,  453 


872 


INDEX. 


Sciatica,  669 

Sclerema,  820 

Scleroderma,  820 

Sclerosis,  amyotrophic  lateral,  641,  646 

anterolateral,  646 

cerebral,  653 

cerebrospinal,  653 

combined  lateral  and  posterior,  652 

disseminated,  653 

lateral,  645,  646,  657 

of  the  brain  and  cord,  multiple,  653 

of  the  kidneys,  359 

posterior,  645,  646 
spinal,  648 

primary  lateral,  646 

spinal,  645,  653 
Scolices,  288 
Scorbutic  purpura,  178 
Scorbutus,  178 
Scrofuloderma,  829 
Scurvy,   178 

infantile,  179 
Sebaceous  cyst,  817 

tumor,  817 
Seborrhea,  841 
Seborrheic  eczema,  755 

congest! va,  824 

oleosa,  842 
•  capitis,  842 

sicca,  842 
Secondary  anemia,  390 

bronchitis,  529 

cerebral  abscess,  607 

dementia,  721 

syphilis,  77 
Secretion,  disorders  of,  835 
Senile,  emphysema,  546 

melancholia,  696 

vertigo,  616 
Sensation,  disorders  of,  845 
Sense,  muscular,  574 

of  position,  574 
Sensory,  aphasia,  613,  614 

area,  590 

phenomena,  572 
Septic  endocarditis,  429 
Sequels,  4 
Serous  apoplexy,  622 

stools,  260 
Serpiginous  tubercular  syphiloderm,   832 
Seven-day  fever,  38 


Shaking  palsy,  691 
Shiga's  bacillus,  103 
Shingles,  666 
Ship  fever,  32 
Shortness  of  breath,  500 
Sick  headache,  619 
Sign,  Graefe's,  405 

Kemig's,  3  5,  36 

Moebius',  405 

Rovsing's,  280 

Stellwag's,  405 
Simple  angina,  210 

continued  fever,  1 1 

dilatation  (cardiac),  449 

exudative  endocarditis,  426 

hypertrophy  (cardiac),  446 

neuritis,  660 

stomatitis,  201 

ulcer,  234 
Skin,  anemia  of,  724 

anesthesia  of,  573 

atrophies  of,  819 

diseases  of,  722 

glossy,  574 

hyperemia  of,  724 

hypertrophies  of,  803 

inflammations  of,  725 

lesions  of,  723 

new  growths  of,  823 

syphilis  of,  829 

trophic  disturbances  of,  575 
Sleeping  sickness,  no 
Small-pox,  69 
Small  pulse,  417 

red  kidney,  359,  362 

white  kidney,  362 
Smoker's  patches,  209 

tongue,  209 
Snuffles,  833 
Soft  pulse,  418 
Softening,  cerebral,  602 

of  the  cord,  631 
Somnambulism,  576 
Soor,  204 

Sore  mouth,  putrid,  203 
"  Sore  throat,"  210,  511 

clergyman's,  211 
Sounds,  respiratory,  in  disease,  49  1 

in  health,  488 
Spasm  of  glottis,  518 
Spasmodic  asthma,  540 


INDEX. 


873 


Spasmodic  croup,  82,  516 

laryngitis,  516,  518 

tabes  dorsalis,  646 
Spastic  gait,  570 

paraplegia  primary,  657 

spinal  paralysis,  646 
Spermatozoa  in  urine,  ,350 
Special  senses,  disturbances  of,  577 
Specific  causes  of  disease,  2 

gravity  method,  .384 
of  the  blood,  383 
Speech  center,  590 
Spinal  congestion,  625 

hyperemia,  625 

leptomeningitis,  629 

muscular  atrophy,  chronic,  641 

paralysis,  spastic,  646 
Spinal  cord,  diseases  of,  625 

hyperemia,  625 

localization,  633 

meningitis,  627 

pachymeningitis,  627 

paralysis,  infantile,  636 

sclerosis,  645 
posterior,  648 

softening  of  the,  631 
Spirals,  Curschmann's,  503 
Spirillum  fever,  38 
Spirochseta  cholerse,  95 

Obermeieri,  38,  40 

pallida,  829 
Splenic  anemia,  402 

fever,  116 

leukocythemia,  398,  400 

pseudo-leukemia,  402 
Spleno-myelogenous  leukemia,  400 
Spontaneous  gangrene,  575,  688 
Sporadic  cholera,  268 

diseases,  3 
Spotted  fever,  32,  34 
Sputum,  502 
St.  Anthony's  fire,  78 
St.  Vitus'  dance,  675 
vStarch-products,  test  for,  223 
Status  epilepticus,  679 

lymphaticus,  402 
Steatoma,  817 

Stegomyia  fasciata,  42,  46,  53 
Stellwag's  sign,  405 
Stenocardia,  464 
Stenosis,  aortic,  435,  440 


Stenosis,  mitral,  439 

pulmonary,  442 

tricuspid,  442 
Steppage  gait,  570 
"Stitch  in  the  side,"  560 
Stomach,  cancer  of,  238 

diagnostic  technic,  218 

dilatation  of,  242 

diseases  of,  218 

examination  of,  219 

external  examination  of,  219 

hemorrhage  from,  245 

internal  examination  of,  219 

neuralgia  of,  246 

tube,  contraindications  of,  220 

ulcer  of,  234 
Stomach-contents,  examination  of,  219 

reaction  of,  220 
Stomachic  colic,  246 
Stomatitis,  aphthous,  202 

catarrhal,  201 

chronic,  202 

croupous,  202 

epidemic,  94 

erythematous,  201 

fetid,  203 

follicular,  202 

herpetic,  202 

gangrenous,  205 

mercurial,  206 

mycotic,  204 

parasitic,  204 

simple,  201 

ulcerative,  203 

vesicular,  202 
Stomatomycosis,  204 
Stone  in  the  kidney,  368 
Stools,  260 

Strangulation,  intestinal,  283,  286 
Strawberry  tongue,  61 
Streptococcus  erysipelatis,  78 
Strobila,  289 
"Stroke,"  595 
Strong  pulse,  418 
Subacidity,  220 

Subacute  disease,  definition  of,  3 
Subjective     symptoms    of    skin    diseases, 

724 
Subsultus  tendinum,  19 
Succussion,  499 
Sudamen,  838 


874 


INDEX. 


Sudamina,  838 

Sugar  in  the  Urine,  342 

Summer  complaint,  274 

Sun  cholera  mixture,  loi 

Sunstroke,  198 

Superficial  cardiac  space,  410 

Superfluous  hair,  818 

Suppressed  respiration,  491 

Suppurative  encephalitis,  607 

hepatitis,  302 

nephritis,  366 

pancreatitis,  322 
Surgical  kidney,  366 
Swamp  fever,  41 
Sweating,  diminished,  838 

excessive,  835 
Sycosis,  lupoid,  773 

parasitica,  791 

vulgaris,  772 
Sydenham's  chorea,  675 
Symptom,  Argyll-Robertson,  649 
Symptomatology,  definition  of,  3 

of  diseases  of  the  circulatory  system, 
416 

of  nervous  diseases,  568 

of  skin  diseases,  722 
Syphilis  cutanea,  829 

hereditary,  77 

of  the  liver,  312 

of  the  skin,  829 

of  the  tongue,  208 

secondary,  77 
Syphilitic  laryngitis,  521,  523 
Syphiloderma,  829 
Syringomyelia,  658 
Syringomyelitis,  658 
Systolic  dimpling,  425 

Tabes  dorsalis,  648 

spasmodic,  646 
Table    or    tables : 

differentiating  ascites,  ovarian  tu- 
mors, pregnancy,  and  distended 
bladder,  332 

differentiating  bronchitis,  influenza 
and  bronchopneumonia,  526 

differentiating  carcinoma  and  cir- 
rhosis of  the  liver,  314 

differentiating  cerebral  tumor,  cere- 
bral abscess,  and  tubercular 
meningitis,  612 


differentiating  chronic  diseases  of  the 

spinal  cord,  657 
differentiating   chronic   gastritis   and 

dyspepsia,  23  i 
differentiating  gout  and  rheumatism, 

171 
differentiating       hematemesis       and 

hemoptysis,  246 
differentiating    interstitial    nephritis, 

and  arteriosclerosis,  363 
differentiating       neurasthenia       and 

hysteria,  686 
differentiating  simple  meningitis  and 

tubercular  meningitis,  587 
differentiating  syphilitic  and  tubercu- 
lar ulcers  of  the  larynx,  523 
differentiating      true      angina      and 

pseudoangina,  466 
differentiating    vaccino-syphilis    and 

hereditary  syphilis,  77 
differentiating    vaccino-syphilis    and 

vaccination  rashes,  77 
differentiating    vaccino-syphilis    and 

vaccination  ulcers,  76 
differentiating    varieties    of    Bright 's 

disease,  362 
differentiating  varieties  of  dyspepsia, 

250 
differentiating  varieties  of  intestinal 

obstruction,  286 
differentiating   yellow   fever,    dengue 

and  malarial  fevers,  57 
of  aneurysms  of  the  aorta,  472 
of  association  of  physical  signs,  500 
of  cardiac  movements,  412 
of  exanthemata,  10 
of  forms  of  aphasia,  614 
of  forms  of  insanity,  695 
of  heart  action,  412 
of  hypertropic  and  atrophic  cirrho- 
sis of  the  liver,  308 
of  incubation  periods,  9 
of  liver  dullness,  299 
of  localization  of  spinal  functions, 

633 
of  mosquitoes,  42 
of  poisons  and  antidotes,  227 
of  skin  lesions,  723 
of  symptoms,  etc.,  of  paralysis  of 

the  laryngeal  muscles,  675 
of  temperature  and  pulse,  8 


INDEX. 


87: 


Tache  cerebrale,  582 
Tachycardia,  416,  461 
Taenia  echinococcus,  287,  288,  290,  .311 
niediocanellata,  288 
saginata,  287,  288,  289 
solium,  287,  288,  289 
Talipes  calcaneus,  638 
cavus,  638 
equinus,  638 
Tapeworms,  287,  289 
Telegraphist's  cramp,  690 
Temperature,  6 
subnormal,  6 
relation  of,  to  pulse,  8 
Temulentia,  188,  189 
Tendon  reflexes,  571 
Tension  of  the  pulse,  418 
Termination  of  diseases,  5 
Terminology,  5 
Tertian  fever,  43 
parasite,  43 
Test,  or  tests: 
Boas',  221 
Boettger's,  342 
Davy's,  336 
Ehrlich's  diazo,  346 
Esbach's,  341 
Fehling's,  343 
for  acetic  acid,  222 
for  acetone,  345 
for  albumin,  341 
for  alcohol,  222 
for  bile,  344,  345 
for  blood  in  the  urine,  344 
for  butyric  acid,  222 
for  chlorids,  339 
for  determination  of  motor  power  of 

the  stomach,  224 
for  diacetic  acid,  346 
for  free  acids,  220 
for  hydrochloric  acid,  221 
for  indican,  346 
for  lab  ferment,  223 
for  lactic  acid,  222 
for  pepsin,  223 
for  peptone,  223,  346 
for  phosphates,  339 
for  propeptone,  223 
for  pus,  345 

for    rate    of    absorption    of    stomach 
contents,  224 


Test  for  rennet,  223 

for  starch  products,  342 

for  total  acidity  of  the  gastric  con- 
tents, 22  1 

for  urates,  337 

for  urea,  336 

for  uric  acid,  337 

Fowler's,  336 

Gmelin's,  345 

Giinzburg's,  221 

heat  and  nitric  acid,  341 

Heller's,  341,  344 

Jaffe's,  346 

Johnson,  341,  342 

Legal's,  345 

Lieben's,  223 

Moore's,  342 

Pettenkofer's,  345 

phenyl  hydrazin,  343 

Ralfe's,  343 

Roberts',  343 

Toepfer's,  221 

Trommer's,  342 

tuberculin,  152 

Uffelmann's,  222 
Test  meal.  Boas',  219 

Ewald's,  219 

Leube-Riegel,  219 
Tetanic  convulsions,  569 
Tetanilla,  689 
Tetanus,  112 

cephalic,  112 

indiopathic,  112 

neonatorum,  112 

traumatic,  112 
Tetany,  518,  689 
Tetter,  733 
Thermic  fever,  198 
Thermoanesthesia  ,573 
Thoma-Zeiss  method,  385 
Thoracic  aorta,  aneurysm  of  the,  473 
Throat  consumption,  522 
Thrombosis,  cerebral-,  602 
Thrush,  204 
Thymic  asthma,  518 
Tic-doulourex,  668 
Tinea  circinata,  785,  789 
circinata  crusis,  786 
favosa,  794 

epidermidis,  795 
pilaris,  795 


876 


INDEX. 


Tinea  favosa,  pilaris  et  capitis,  795 
unguinm,  795 

furfuracea,  841 

kerion,  788,  789 

sycosis,  791 

tonsurans,  788 

tricophytina  barbae,  197 
capitis,  788 
corporis,  785 
unguium,  786 

versicolor,  793 
Tinnitus  aurium,  577 
Titubation,  571 
Toepfer's  test,  221 
Tongue,  coating  of,  207 

diseases  of,  207 

smoker's,  209 

syphilis  of,  208 

ulceration  of,  208 
Tonsillar  abscess,  213 
Tonsillitis,  acute,  213 
Tonsils,  diseases  of,  210 

hypertrophy  of,  215 
Tormina,  256 
Torpid  liver,  300 
Torpor,  intestinal,  257 
Torticollis,  164,  165 
Total  acidity  of  gastric  contents,  221 
Toxic  erythema,  725 

gastritis,  225,  227 
Tracheal  rales,  495 
Trance,  576 

Transitional  lymphocytes,  386 
Transverse  myelitis,  63 1 
Traube's  semilunar  space,  218,  485 
Traumatic  pneumonia,  134 

tetanus,  112 
Tremors,  569 

Treponema,  pallidum,  829 
Trichina  spiralis,  291,  292,  293 
Trichiniasis,  295 

Trichocephalus  dispar,  291,  292,  294 
Tricophyton,  785,  788,  791 
Tricuspid  insufficiency,  434,  438 

obstruction,  442 

regurgitation,  434,  438 

stenosis,  442 
Triple  phosphate,  337 
Trismus,  112 

Trommer's  test  for  sugar,  342 
Trophic  disturbances  of  the  skin,  575 


True  aneurysm,  470 

croup,  82 
Trypanosoma  gambiense,  no 

hominis,  no 
Trypanosomiasis,  no 
Tubal  nephritis,  acute,  352 

chronic,  355 
Tube  casts,  348 
Tubercle  bacillus,  504 

bacilli  in  urine,  349,  350 
Tubercles,  149,  724 
Tubercular  meningitis,  585,  612 

phthisis,  141,  148 

syphiloderm,  832 

ulcer  of  intestine,  17 
Tuberculin  test,  152 
Tuberculosis,  141,  148 

acute  miliary,  142 

of  the  kidney,  372 
pulmonary,  141,  143 
Tuberculous  laryngitis,  522 
Tumor,  cerebral,  609 

encysted,  817 

intracranial,  609 

phantom,  685 

sebaceous,  817 
Tumors,  724 
Tunnel  anemia,  296 
Tussive  fremitus,  481 
Tyloma,  807 
Tympanitic  note,  486 
Types  of  fever,  7 
Typhilitis,  277 
Typhoid  carriers,  25 

cholera,  95 

fever,  16 

variety  of  tuberculosis,  142 
Typho- malarial  fever,  24,  48 
Typhoid  pneumonia,  133 

ulcer  of  intestine,  17 
Typhus,  abdominal,  16 

exanthematic,  32 

fever,  32 

icterodes,  53 

petechial,  32 
Tyrosin,  339,  341 

Uffelmann's  test,  222 

Ulcer,  duodenal,  234 

gastric,  234 


INDEX. 


877 


Ulcer  of  the  pharynx,  212 

of  the  stomach,  234 

of  the  tongue,  208 

peptic,  234 

round,  234 

simple,  234 

tubercular,  of  the  intestine,  17 

typhoid,  of  the  intestine,  17 
Ulcerative  endocarditis,  426,  429 

enterocolitis,  270 

stomatitis,  203 
Ulcers,  vaccination,  76 
Uncinaria,  293 
Uncinariasis,  296 
Undulant  fever,  40 
Unequal  pupils,  577 
Universal  eczema,  746 
Urate,  ammonium,  338 
Urates,  337 
Urea,  336 
Uremia,  acute,  373 
Uremic  coma,  373 

convulsions,  373 

intoxication,  373 

poisoning,  373 
Uric  acid,  337 

acid  crystals,  337 

acid  diathesis,  173 

acid,  tests  for,  337 
Uricemia,  173 
Uridrosis,  836 
Urinalysis,  334 

Urinary  organs,  diseases  of,  334 
Urine,  334 

composition  of,  335 

microscopic  examination  of,  347 
Urticaria,  728 

ab  ingestis,  730 

annularis,  729 

bullosa,  729 

conferta,  730 

evanida,  730 

factitia,  730 

febrilis,  730 

figurata,  729 

haemorrhagica,  730 

papulosa,  729 

perstans,  730 

pigmentosa,  730,  732 

purpurata,  730 

tuberosa,  730 


Urticaria,  types  of,  632 
vesiculosa,  729 

Vaccinia,  75 
Vaccination,  75 

rashes,  77 

ulcers,  77 
Vaccino-chancre,  76 

-syphilis,  76,  77 
Valvular  defects,  combined,  443 
relative  frequency  of,  442 

diseases,  chronic,  430 
diagnosis  of,  443 
treatment  of,  444 
Valvulitis,  426 
Varicella,  77 
Variola,  69 

Varioliformis  syphilide,  831 
Varioloid,  70,  72 
Vasomotor  disturbances,  572 
Ventricular  hemorrhage,  598 
Vemix  caseosa,  841 
Verruca,  812 

acuminata,  813 

digitata,  813 

filiformis,  813 

plana,  812 

vulgaris,  812 
Vertigo,  615 

auditory,  615 
Vesicles,  723 
Vesicular  emphysema,  545 

rales,  496 

stomatitis,  202 

syphiloderm,  831 
Vesiculobronchial  respiration,  493 
Violin-player's  cramp,  690'- 
Visual  center,  590 
Vitiligo,  819 
Vitiligoidea,  823 
Vleminckx's  solution,  771 
Vocal  cords,  674 

fremitus,  481 

resonance,  498 
Voice  in  health,  490 

in  disease,  498 
Volvulus,  283,  286 
Vomit,  black,  53 
von  Fleischl's  hemoglobinometer,  3  J 

Walking  typhoid  fever,  23 


878- 


INDEX. 


Wandering  kidney,  377 
Wart,  812 
Wasting  palsy,  641 
Water-cancer,  205 
Water-hammer  pulse,  417,  436 
Water-on- the-brain- ,  622 
Watery  stools,  260 
Waxy  casts,  349 

kidney,  364 

liver,  309 
Weak  pulse,  418 

Weichselbaum's  diplococcus,  34.  3  5 
Wen,  817 

Westphal's  symptom,  649 
Wheals,  723 
White  blood-cells,  386 

kidney,  small,  362 
Whooping  cough,  118 
Widal  reaction,  23 
Winter  cough,  529 
Wool-sorter's  disease,  116 


Word  blindness,  614 
deafness,  613,  614 

Worms,  814 

round,  291 

Wrist-drop,  663 

Writer's  cramp,  690 

Xanthelasma,  823 
Xanthoma,  823 

planum,  823 

tuberosum,  823 
Xeroderma,  810 

Yellow  atrophy,  acute,  304 
fever,  53.  5  7 
hepatization,  129 
Jack,  53 

Zona,  666 

Zoster,  herpes,  666 


J 


l^?l 


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